MEDICARE: MR. JOEL SHANE WILSON MS, LPCC

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	0550	KY
2	101YP2500X	Professional Counselor	18552	TX
3	101YP2500X	Professional Counselor	103656	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0550	OTHER	KY	LICENSE PROFESSIONAL CLINICAL COUNSELOR
2	11662641	OTHER		CAQH PROVIDER ID
3	18552	OTHER	TX	LICENSE PROFESSIONAL COUNSELOR
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	61254	OTHER		NATIONAL CERTIFIED COUNSELOR
7	103656	OTHER	KY	UPDATED KY LICENSE PROFESSIONAL COUNSELOR NUMBER

General Provider Information

NPI Number	:	1720198294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOEL SHANE WILSON MS, LPCC

Provider Business Mailing Address
First Line	:	10011 SEATONVILLE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3541
Country	:	US
Telephone Number	:	502-472-9833
Fax Number	:	502-805-0600

Provider Business Practice Location Address
First Line	:	155 LEES VALLEY RD
Second Line	:
City	:	SHEPHERDSVILLE
State	:	KY
Zip	:	40165-6143
Country	:	US
Telephone Number	:	502-472-9833
Fax Number	:	502-805-0600

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	03/01/2022

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