Provider Demographics
NPI:1447968052
Name:OTU, SHANNON WILSON (MSW, LCSW-A)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:WILSON
Last Name:OTU
Suffix:
Gender:F
Credentials:MSW, LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 SUNSET AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3751
Mailing Address - Country:US
Mailing Address - Phone:252-902-4099
Mailing Address - Fax:
Practice Address - Street 1:2747 SUNSET AVE STE 109
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3751
Practice Address - Country:US
Practice Address - Phone:252-902-4099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0182451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical