Provider Demographics
NPI:1275223596
Name:REEDY, SHANNON LEIGH SMITH (LCMHCA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH SMITH
Last Name:REEDY
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15961 FOX LN
Mailing Address - Street 2:
Mailing Address - City:WAGRAM
Mailing Address - State:NC
Mailing Address - Zip Code:28396-9740
Mailing Address - Country:US
Mailing Address - Phone:910-992-9571
Mailing Address - Fax:
Practice Address - Street 1:753 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376
Practice Address - Country:US
Practice Address - Phone:910-490-2037
Practice Address - Fax:910-479-1711
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health