Provider Demographics
NPI:1427622448
Name:WISE, SHANNON MICHELLE (MS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:WISE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:7731 BELLEFIELD DR E
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-2365
Mailing Address - Country:US
Mailing Address - Phone:251-510-0897
Mailing Address - Fax:
Practice Address - Street 1:820 N ALSTON ST STE A
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-3510
Practice Address - Country:US
Practice Address - Phone:251-269-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3571101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional