Healthcare Provider Details

I. General information

NPI: 1619096393
Provider Name (Legal Business Name): SHANIKA LAVI WILSON DSW, LCAS, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANIKA LAVI RENFRO LCSW, MSW

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 TWO NOTCH RD
COLUMBIA SC
29223-4304
US

IV. Provider business mailing address

9600 TWO NOTCH RD
COLUMBIA SC
29223-4304
US

V. Phone/Fax

Practice location:
  • Phone: 803-310-2774
  • Fax:
Mailing address:
  • Phone: 803-310-2774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2795
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ5-0000350
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC006604
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18932
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: