Provider Demographics
NPI:1497096218
Name:CLARKE, SHAWANDA B (BA, MED)
Entity Type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:B
Last Name:CLARKE
Suffix:
Gender:F
Credentials:BA, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MUMSFORD CT
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-3471
Mailing Address - Country:US
Mailing Address - Phone:470-257-1371
Mailing Address - Fax:
Practice Address - Street 1:120 MUMSFORD CT
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-3471
Practice Address - Country:US
Practice Address - Phone:470-257-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker