Provider Demographics
NPI:1700284668
Name:WHEELER, ANNASTATIA SHANNON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANNASTATIA
Middle Name:SHANNON
Last Name:WHEELER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MT
Mailing Address - Zip Code:59825-0361
Mailing Address - Country:US
Mailing Address - Phone:406-207-3913
Mailing Address - Fax:
Practice Address - Street 1:725 W CENTRAL AVE STE 109
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6867
Practice Address - Country:US
Practice Address - Phone:406-207-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9755104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7171710Medicaid