Provider Demographics
NPI:1942040506
Name:WISE, SHANNON M (MM, MS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:MM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 MASON MILL CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5740
Mailing Address - Country:US
Mailing Address - Phone:703-577-3005
Mailing Address - Fax:
Practice Address - Street 1:3925 BLENHEIM BLVD STE 52B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2426
Practice Address - Country:US
Practice Address - Phone:571-418-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016928101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health