Provider Demographics
NPI:1114502853
Name:CONLEY, SHAMIKA RUTH
Entity Type:Individual
Prefix:
First Name:SHAMIKA
Middle Name:RUTH
Last Name:CONLEY
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 1:103 SOUTHLAKE CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5369
Mailing Address - Country:US
Mailing Address - Phone:601-859-8371
Mailing Address - Fax:
Practice Address - Street 1:103 SOUTHLAKE CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5369
Practice Address - Country:US
Practice Address - Phone:601-859-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health