Provider Demographics
NPI:1477298362
Name:GREGORY, SHANTE DENISE (LCMCHA)
Entity Type:Individual
Prefix:MRS
First Name:SHANTE
Middle Name:DENISE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LCMCHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13663 PROVIDENCE RD # 355
Mailing Address - Street 2:
Mailing Address - City:WEDDINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28104-9373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5665
Practice Address - Country:US
Practice Address - Phone:704-438-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health