Provider Demographics
NPI:1497431043
Name:CONLEY, SHANA GISSENTANNER (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:GISSENTANNER
Last Name:CONLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SHANA
Other - Middle Name:NICOLE
Other - Last Name:GISSENTANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4150 EDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7551
Mailing Address - Country:US
Mailing Address - Phone:678-851-9177
Mailing Address - Fax:
Practice Address - Street 1:2760 PEACHTREE INDUSTRIAL BLVD STE C
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2201
Practice Address - Country:US
Practice Address - Phone:404-919-0917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0090151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical