Provider Demographics
NPI:1497484208
Name:SHUMPERT, GEORGIA
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:SHUMPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14413 REDDINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3213
Mailing Address - Country:US
Mailing Address - Phone:216-337-5859
Mailing Address - Fax:
Practice Address - Street 1:14413 REDDINGTON AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3213
Practice Address - Country:US
Practice Address - Phone:216-337-5859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.22034951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty