Provider Demographics
NPI:1457030603
Name:WILSON, SHAVONA (LSW)
Entity type:Individual
Prefix:
First Name:SHAVONA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9168 ELLIE DR # B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2857
Mailing Address - Country:US
Mailing Address - Phone:856-412-1769
Mailing Address - Fax:
Practice Address - Street 1:9168 ELLIE DR # B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2857
Practice Address - Country:US
Practice Address - Phone:856-412-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW139889104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker