Provider Demographics
NPI:1083287742
Name:SHIVELY, AUSTIN THOMAS (LAPC)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:THOMAS
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 WHEELER RD STE 365
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6549
Mailing Address - Country:US
Mailing Address - Phone:706-432-6866
Mailing Address - Fax:706-432-8775
Practice Address - Street 1:3633 WHEELER RD STE 365
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6549
Practice Address - Country:US
Practice Address - Phone:706-432-6866
Practice Address - Fax:706-432-8775
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GAAPC008650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor