Provider Demographics
NPI:1053460402
Name:SOUTH, SHANNON DENISE (MA,, THD, LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DENISE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:MA,, THD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-4150
Mailing Address - Country:US
Mailing Address - Phone:828-230-5477
Mailing Address - Fax:
Practice Address - Street 1:1 ZILLICOA ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-1038
Practice Address - Country:US
Practice Address - Phone:828-230-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist