Healthcare Provider Details

I. General information

NPI: 1265892889
Provider Name (Legal Business Name): SHAWN L WILLSON M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 MISSION RD BLDG 2, STE 111
PRAIRIE VILLAGE KS
66208-3006
US

IV. Provider business mailing address

7301 MISSION RD BLDG 2, STE 111
PRAIRIE VILLAGE KS
66208-3006
US

V. Phone/Fax

Practice location:
  • Phone: 913-381-4200
  • Fax: 913-381-4201
Mailing address:
  • Phone: 913-381-4200
  • Fax: 913-381-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number0433574
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0433574
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number0433574
License Number StateKS

VIII. Authorized Official

Name: PATRICIA LYNN DEFREECE
Title or Position: MANAGER
Credential:
Phone: 913-381-4200