Provider Demographics
NPI:1508259557
Name:DALE, SHANTA (LPC-CR)
Entity Type:Individual
Prefix:MRS
First Name:SHANTA
Middle Name:
Last Name:DALE
Suffix:
Gender:F
Credentials:LPC-CR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 JEFFERSON AVE
Mailing Address - Street 2:STE. 301
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-6955
Mailing Address - Country:US
Mailing Address - Phone:419-321-6455
Mailing Address - Fax:
Practice Address - Street 1:701 JEFFERSON AVE
Practice Address - Street 2:STE. 301
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-6955
Practice Address - Country:US
Practice Address - Phone:419-321-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1300752-CR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional