Provider Demographics
NPI:1164929576
Name:DOUTHAT, SHANNON MOYE (EDS , MS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MOYE
Last Name:DOUTHAT
Suffix:
Gender:F
Credentials:EDS , MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-2134
Mailing Address - Country:US
Mailing Address - Phone:540-921-1421
Mailing Address - Fax:540-921-1424
Practice Address - Street 1:151 SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-2134
Practice Address - Country:US
Practice Address - Phone:540-921-1421
Practice Address - Fax:540-921-1424
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000154103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool