Provider Demographics
NPI:1306202007
Name:ANDERSON, SHANTREZE DESHAE
Entity Type:Individual
Prefix:
First Name:SHANTREZE
Middle Name:DESHAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANTREZE
Other - Middle Name:DESHAE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-8358
Mailing Address - Country:US
Mailing Address - Phone:706-616-4325
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN STREET
Practice Address - Street 2:SUITE 228
Practice Address - City:LAGRANGE
Practice Address - State:GEORGIA
Practice Address - Zip Code:30240
Practice Address - Country:UM
Practice Address - Phone:678-547-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional