Provider Demographics
NPI:1346638673
Name:LEWIS, SHAUN B (LPC)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:B
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2396 PENDERGRASS LN
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-6249
Mailing Address - Country:US
Mailing Address - Phone:484-459-6813
Mailing Address - Fax:
Practice Address - Street 1:2759 DELK RD SE
Practice Address - Street 2:SUITE 1400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8847
Practice Address - Country:US
Practice Address - Phone:678-401-4596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007441101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional