=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720198294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOEL SHANE WILSON MS, LPCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 LEES VALLEY RD
-----------------------------------------------------
City | SHEPHERDSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40165-6143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-472-9833
-----------------------------------------------------
Fax | 502-805-0600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10011 SEATONVILLE RD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40291-3541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-472-9833
-----------------------------------------------------
Fax | 502-805-0600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0550
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18552
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 103656
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------