Provider Demographics
NPI:1316374697
Name:DAWSON, SHAKIERRA
Entity Type:Individual
Prefix:
First Name:SHAKIERRA
Middle Name:
Last Name:DAWSON
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 1:334 TIFTON ELDORADO RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-9497
Mailing Address - Country:US
Mailing Address - Phone:229-391-2300
Mailing Address - Fax:229-671-6774
Practice Address - Street 1:3120 N OAK STREET EXT STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5910
Practice Address - Country:US
Practice Address - Phone:229-671-6100
Practice Address - Fax:229-671-6774
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003322101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003322OtherLICENSE