Provider Demographics
NPI:1881707610
Name:WILSON, SHANNON KATHLEEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23461 S POINTE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1547
Mailing Address - Country:US
Mailing Address - Phone:949-235-1081
Mailing Address - Fax:
Practice Address - Street 1:23461 S POINTE DR STE 220
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1523
Practice Address - Country:US
Practice Address - Phone:949-855-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical