Provider Demographics
NPI:1851663710
Name:SHAFFER, EMMETT GLENN (EDD)
Entity Type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:GLENN
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LIRAC CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8146
Mailing Address - Country:US
Mailing Address - Phone:770-362-9999
Mailing Address - Fax:
Practice Address - Street 1:3615 OLD MILTON PARKWAY
Practice Address - Street 2:3615
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005
Practice Address - Country:US
Practice Address - Phone:770-310-9225
Practice Address - Fax:678-205-4858
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004199101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional