Provider Demographics
NPI:1619548716
Name:ALLEYNE-GRANT, SHIRNEL
Entity Type:Individual
Prefix:
First Name:SHIRNEL
Middle Name:
Last Name:ALLEYNE-GRANT
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 1:2204 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1107
Mailing Address - Country:US
Mailing Address - Phone:404-357-1506
Mailing Address - Fax:
Practice Address - Street 1:2204 RIVER RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1107
Practice Address - Country:US
Practice Address - Phone:404-357-1506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional