Provider Demographics
NPI:1013402247
Name:WALLON, SHANNON BURGE (LAPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:BURGE
Last Name:WALLON
Suffix:
Gender:F
Credentials:LAPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4835
Mailing Address - Country:US
Mailing Address - Phone:470-334-3334
Mailing Address - Fax:
Practice Address - Street 1:5755 N POINT PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:678-644-0039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006442101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor