Provider Demographics
NPI:1275961039
Name:CROSSLIN, SHANNON LYNETTE
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LYNETTE
Last Name:CROSSLIN
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 1:608 SAINT CHRISTOPHER LN
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2999
Mailing Address - Country:US
Mailing Address - Phone:770-316-6582
Mailing Address - Fax:678-284-0506
Practice Address - Street 1:608 SAINT CHRISTOPHER LN
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2999
Practice Address - Country:US
Practice Address - Phone:770-316-6582
Practice Address - Fax:678-284-0506
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health