Provider Demographics
NPI:1124363718
Name:STATEN, SHASTA GABRIELLE (MED, LPC)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:GABRIELLE
Last Name:STATEN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12664 PERSIMMON TREE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-8024
Mailing Address - Country:US
Mailing Address - Phone:704-621-1095
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK RD STE 218B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional