Provider Demographics
NPI:1235839820
Name:DAVIDSON, SHANNON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 TRACE CHAIN CT
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3919
Mailing Address - Country:US
Mailing Address - Phone:678-682-0405
Mailing Address - Fax:
Practice Address - Street 1:126 ENTERPRISE PATH STE 201
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2654
Practice Address - Country:US
Practice Address - Phone:678-682-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0084971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical