MEDICARE: SHANNON WILD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1861750747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON WILD

Provider Business Mailing Address
First Line	:	37690 CHARTER OAKS BLVD
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48036-2424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 CATALPA DR
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-1125
Country	:	US
Telephone Number	:	248-971-0383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2012
Last Update Date	:	04/27/2012

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Directions to “ SHANNON WILD ” Practice Location

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