Provider Demographics
NPI:1720190234
Name:KERSEY, SHANNON ELIZABETH (LPA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:KERSEY
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 RANDOLPH RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2351
Mailing Address - Country:US
Mailing Address - Phone:704-323-6586
Mailing Address - Fax:
Practice Address - Street 1:4425 RANDOLPH RD
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2351
Practice Address - Country:US
Practice Address - Phone:704-323-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2531103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107171Medicaid