Provider Demographics
NPI:1326390196
Name:FORSTALL, SHANTEL M (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:M
Last Name:FORSTALL
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 1:110 HABERSHAM DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1381
Mailing Address - Country:US
Mailing Address - Phone:770-371-5076
Mailing Address - Fax:
Practice Address - Street 1:110 HABERSHAM DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1381
Practice Address - Country:US
Practice Address - Phone:770-371-5076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0046811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical