Provider Demographics
NPI:1700648748
Name:WILSON, SHARELL WINONA (LSW)
Entity Type:Individual
Prefix:
First Name:SHARELL
Middle Name:WINONA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:SHARELL
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:109 N CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-1305
Mailing Address - Country:US
Mailing Address - Phone:267-410-6188
Mailing Address - Fax:
Practice Address - Street 1:7116 CLINTON RD STE A
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-5212
Practice Address - Country:US
Practice Address - Phone:856-629-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137968104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker