Provider Demographics
NPI:1568855500
Name:SHIRAH, MARINENA RACHELLE
Entity Type:Individual
Prefix:
First Name:MARINENA
Middle Name:RACHELLE
Last Name:SHIRAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARINENA
Other - Middle Name:RACHELLE 'RAE'
Other - Last Name:SHIRAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:389 LOWER DUG GAP RD SW
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-9239
Mailing Address - Country:US
Mailing Address - Phone:706-463-8053
Mailing Address - Fax:
Practice Address - Street 1:900 SHUGART RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2467
Practice Address - Country:US
Practice Address - Phone:706-270-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional