Provider Demographics
NPI:1093145666
Name:PARKS, CEISHA SHADOR
Entity Type:Individual
Prefix:
First Name:CEISHA
Middle Name:SHADOR
Last Name:PARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 WINSTON TRCE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-6896
Mailing Address - Country:US
Mailing Address - Phone:678-559-8873
Mailing Address - Fax:
Practice Address - Street 1:6040 WINSTON TRACE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252
Practice Address - Country:US
Practice Address - Phone:612-559-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health