Provider Demographics
NPI:1376301572
Name:SHOCK, CARSON
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:SHOCK
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 1:327 DAHLONEGA ST STE B1902
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8216
Mailing Address - Country:US
Mailing Address - Phone:678-371-7357
Mailing Address - Fax:
Practice Address - Street 1:327 DAHLONEGA ST STE B1902
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8216
Practice Address - Country:US
Practice Address - Phone:678-371-7357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009560101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health