Individual
SHANNON L WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
90 HOPE DR BLDG 6000, MOUNTAIN HOME AFB, ID 83648-1062
(208) 288-7580
Mailing address
90 HOPE DR BLDG 6000, MOUNTAIN HOME AFB, ID 83648-1062
(208) 828-7500
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
LMSW-33063
ID
1041C0700X
Clinical Social Worker
Primary
LCSW-36402
ID
Other
Enumeration date
05/22/2015
Last updated
12/01/2025
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