| Doctor Name: | MS. SHANNON AMBER WILSON |
| NPI Number: | 1013225754 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW |
| License Number: | MC12620 |
| Business Practice Address: | 3535 N California Ave Suite F Peoria, IL - 616031178 |
| Business Phone Number: | 3096862153 |
| Business Fax Number: | 8883716976 |
| Mailing Address: | 1215 Royal Pointe Dr, BLOOMINGTON |
| State: | IL |
| Postal Code: | 617048213 |
| Phone Number: | 2697534826 |
| Fax Number: | |
| NPI Enumeration Date: | 09/15/2010 |
| NPI Last Update Date: | 09/12/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | MC12620 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | ME |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |