Healthcare Provider Details

I. General information

NPI: 1013396175
Provider Name (Legal Business Name): SHANNON L WILSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 208-288-7580
  • Fax:
Mailing address:
  • Phone: 208-828-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36402
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-33063
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: