Healthcare Provider Details

I. General information

NPI: 1558257675
Provider Name (Legal Business Name): SHELLY WIMS LPC, ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11701 W FLORISSANT AVE
FLORISSANT MO
63033-6744
US

IV. Provider business mailing address

1001 LYNCH ST
SAINT LOUIS MO
63118-1818
US

V. Phone/Fax

Practice location:
  • Phone: 314-830-2565
  • Fax:
Mailing address:
  • Phone: 314-535-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2016040796
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2025044325
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: