Provider Demographics
NPI:1477215051
Name:MAHMUTOVIC, SHANNON NICOLE (LCASA, LCMHCA, MA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MAHMUTOVIC
Suffix:
Gender:F
Credentials:LCASA, LCMHCA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 HOUNDSCROFT RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-8818
Mailing Address - Country:US
Mailing Address - Phone:980-402-2686
Mailing Address - Fax:
Practice Address - Street 1:16507 NORTHCROSS DR STE F
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5082
Practice Address - Country:US
Practice Address - Phone:704-277-8197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-26801101YA0400X
NCA16640101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health