Provider Demographics
NPI:1750609905
Name:WILKINSON, ROBERT SHAWN (LCPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SHAWN
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 FALLS AVE STE 1280
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3364
Mailing Address - Country:US
Mailing Address - Phone:208-736-9990
Mailing Address - Fax:208-736-9995
Practice Address - Street 1:834 FALLS AVE STE 1280
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3364
Practice Address - Country:US
Practice Address - Phone:208-736-9990
Practice Address - Fax:208-736-9995
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4205101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806775900Medicaid