MEDICARE: SHANTIA MARIE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1407289507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTIA MARIE WILSON

Provider Business Mailing Address
First Line	:	18 PEACHTREE LN
Second Line	:
City	:	BURLINGTON
State	:	NJ
Zip	:	08016-2304
Country	:	US
Telephone Number	:	609-325-1842
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 CATHY LN
Second Line	:
City	:	BURLINGTON
State	:	NJ
Zip	:	08016-9727
Country	:	US
Telephone Number	:	609-499-0603
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2013
Last Update Date	:	08/13/2013

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Directions to “ SHANTIA MARIE WILSON ” Practice Location

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