Provider Demographics
NPI:1598338808
Name:MIMBS, SHANNON DAVY (MACMHC, MDIV)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAVY
Last Name:MIMBS
Suffix:
Gender:M
Credentials:MACMHC, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8935
Mailing Address - Country:US
Mailing Address - Phone:912-231-5900
Mailing Address - Fax:
Practice Address - Street 1:304 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8935
Practice Address - Country:US
Practice Address - Phone:912-805-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty