Provider Demographics
NPI:1164856373
Name:HALL, SHANNON LACERNE
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LACERNE
Last Name:HALL
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 1:2515 TOLLIVER DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-6228
Mailing Address - Country:US
Mailing Address - Phone:678-794-7112
Mailing Address - Fax:404-241-9083
Practice Address - Street 1:2515 TOLLIVER DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-6228
Practice Address - Country:US
Practice Address - Phone:678-794-7112
Practice Address - Fax:404-241-9083
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08137869101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor