MEDICARE: SHANEISE 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	1041C0700X	Clinical Social Worker	6801108730	MI
2	171M00000X	Case Manager/Care Coordinator	6801091099	MI

General Provider Information

NPI Number	:	1568841336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEISE WILSON

Provider Business Mailing Address
First Line	:	35373 FOREST ST
Second Line	:
City	:	WAYNE
State	:	MI
Zip	:	48184-1760
Country	:	US
Telephone Number	:	734-331-0058
Fax Number	:

Provider Business Practice Location Address
First Line	:	35373 FOREST ST
Second Line	:
City	:	WAYNE
State	:	MI
Zip	:	48184-1760
Country	:	US
Telephone Number	:	734-331-0058
Fax Number	:

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

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/11/2023

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Directions to “ SHANEISE WILSON ” Practice Location

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