Provider Demographics
NPI:1114409711
Name:BREITENBACH, SHANTE
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:BREITENBACH
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 1:204 BELLFLOWER CIR
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-7533
Mailing Address - Country:US
Mailing Address - Phone:910-728-5602
Mailing Address - Fax:
Practice Address - Street 1:135 GOSHEN ROAD EXT STE 203
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5569
Practice Address - Country:US
Practice Address - Phone:912-421-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GALPC010454101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health