Provider Demographics
NPI:1861473100
Name:SHAPIRO, MARY MCCUISTON
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MCCUISTON
Last Name:SHAPIRO
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 1:1601 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-678-0100
Mailing Address - Fax:910-678-7022
Practice Address - Street 1:1601 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-678-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5208103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00596032AMedicaid