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NPI Code Detail

MEDICARE: SHANNON K WALISER LICSW MPA LLC DBA MIND BODY WELLNESS

MEDICARE: SHANNON K WALISER LICSW MPA LLC DBA MIND BODY WELLNESS
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
11041C0700XClinical Social WorkerDP00942521WV

General Provider Information

NPI Number : 1689818379
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHANNON K WALISER LICSW MPA LLC DBA MIND BODY WELLNESS
Provider Business Mailing Address
First Line : PO BOX 1286
Second Line :
City : MORGANTOWN
State : WV
Zip : 26507-1286
Country : US
Telephone Number : 304-363-4265
Fax Number :
Provider Business Practice Location Address
First Line : 295 HIGH ST STE 3
Second Line :
City : MORGANTOWN
State : WV
Zip : 26505-5449
Country : US
Telephone Number : 304-363-4265
Fax Number : 304-999-4826
Authorized Official
Title or Position : OWNER
Name : MS. SHANNON KRISTI WALISER
Credential : MSW, MPA, LICSW
Telephone Number : 304-363-4265
Provider Enumeration Date : 04/24/2009
Last Update Date : 07/22/2020

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