Provider Demographics
NPI:1457158875
Name:WILSON, SHIREE R (RBT)
Entity type:Individual
Prefix:MS
First Name:SHIREE
Middle Name:R
Last Name:WILSON
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:WALKERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46574-1326
Mailing Address - Country:US
Mailing Address - Phone:219-248-5255
Mailing Address - Fax:
Practice Address - Street 1:700 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1620
Practice Address - Country:US
Practice Address - Phone:574-546-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-359456106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty