Provider Demographics
NPI:1851621080
Name:FUSSELL, SHANNON KAY SALTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KAY SALTER
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:KAY
Other - Last Name:SALTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:317 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5138
Mailing Address - Country:US
Mailing Address - Phone:912-225-0258
Mailing Address - Fax:
Practice Address - Street 1:FOREST DR
Practice Address - Street 2:COUNSELING AND CAREER DEVELOPMENT CENTER
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-0001
Practice Address - Country:US
Practice Address - Phone:912-478-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3339103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist