Provider Demographics
NPI:1376608653
Name:COOLEY, SHAWANDALYN LATRELLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHAWANDALYN
Middle Name:LATRELLE
Last Name:COOLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8040 GEORGIA AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4959
Mailing Address - Country:US
Mailing Address - Phone:202-360-4787
Mailing Address - Fax:
Practice Address - Street 1:825 GUM BRANCH RD
Practice Address - Street 2:SUITE 133
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6298
Practice Address - Country:US
Practice Address - Phone:910-346-6726
Practice Address - Fax:910-346-8285
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0049611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300057BMedicaid