Provider Demographics
NPI:1467107045
Name:HARRISON, SHANTELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANTELLE
Middle Name:
Last Name:HARRISON
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 1:5284 FLOYD RD SW UNIT 233
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6102
Mailing Address - Country:US
Mailing Address - Phone:252-903-1480
Mailing Address - Fax:
Practice Address - Street 1:5284 FLOYD RD SW UNIT 233
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-6102
Practice Address - Country:US
Practice Address - Phone:252-903-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0077941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW007794OtherLICENSE
AL5535COtherLICENSE