Provider Demographics
NPI:1366967960
Name:WISNIEWSKI, SHANA HINTZ (LCSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:HINTZ
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:573-426-2108
Practice Address - Street 1:1000 W. 10TH ST.
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-458-7323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170275551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical