Provider Demographics
NPI:1760851828
Name:EDWARDS, SHANNAN MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:MICHELLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 CLAIRMONT RD NE
Mailing Address - Street 2:APARTMENT 447
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1655
Mailing Address - Country:US
Mailing Address - Phone:770-905-7573
Mailing Address - Fax:
Practice Address - Street 1:2924 CLAIRMONT RD NE
Practice Address - Street 2:APARTMENT 447
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1655
Practice Address - Country:US
Practice Address - Phone:770-905-7573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003938103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical