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NPI Code Detail

MEDICARE: DR. SHANNON KATHLEEN WILSON PSY.D.

MEDICARE: DR. SHANNON KATHLEEN WILSON PSY.D.
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
1103TC0700XClinical PsychologistPSY27323CA

General Provider Information

NPI Number : 1881707610
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHANNON KATHLEEN WILSON PSY.D.
Provider Business Mailing Address
First Line : 23461 S POINTE DR
Second Line : SUITE 220
City : LAGUNA HILLS
State : CA
Zip : 92653-1547
Country : US
Telephone Number : 949-235-1081
Fax Number :
Provider Business Practice Location Address
First Line : 23461 S POINTE DR STE 220
Second Line :
City : LAGUNA HILLS
State : CA
Zip : 92653-1523
Country : US
Telephone Number : 949-855-1556
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2006
Last Update Date : 12/22/2022

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