Provider Demographics
NPI:1235655101
Name:EZEDI, SHANNEL (LPCI)
Entity Type:Individual
Prefix:
First Name:SHANNEL
Middle Name:
Last Name:EZEDI
Suffix:
Gender:F
Credentials:LPCI
Other - Prefix:MS
Other - First Name:SHANNEL
Other - Middle Name:
Other - Last Name:EZEDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS, LPCI
Mailing Address - Street 1:1050 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-3679
Mailing Address - Country:US
Mailing Address - Phone:843-473-6355
Mailing Address - Fax:
Practice Address - Street 1:1050 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5400
Practice Address - Country:US
Practice Address - Phone:857-540-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty