Provider Demographics
NPI:1437870771
Name:HOLLOWAY, SHANTALIEA (LPC)
Entity Type:Individual
Prefix:MS
First Name:SHANTALIEA
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:F
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:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-0011
Mailing Address - Country:US
Mailing Address - Phone:678-913-8032
Mailing Address - Fax:
Practice Address - Street 1:1551 ROSE GARDEN LN
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2467
Practice Address - Country:US
Practice Address - Phone:678-913-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty