Provider Demographics
NPI:1558257675
Name:WIMS, SHELLY (MA, PLPC, EDD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:WIMS
Suffix:
Gender:F
Credentials:MA, PLPC, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:417-761-5065
Mailing Address - Fax:
Practice Address - Street 1:11701 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6744
Practice Address - Country:US
Practice Address - Phone:314-830-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016040796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional