Provider Demographics
NPI:1740580182
Name:GONDA, SHALLIS MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:SHALLIS
Middle Name:MICHELLE
Last Name:GONDA
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 1:1155 CULLY RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-8502
Mailing Address - Country:US
Mailing Address - Phone:901-624-2454
Mailing Address - Fax:901-624-2928
Practice Address - Street 1:1155 CULLY RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8502
Practice Address - Country:US
Practice Address - Phone:901-624-2454
Practice Address - Fax:901-624-2928
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health