Provider Demographics
NPI:1902007735
Name:BURDINE-PREVOST, SHELLEY ANNE (LPC-MHSP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:ANNE
Last Name:BURDINE-PREVOST
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4065
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-0065
Mailing Address - Country:US
Mailing Address - Phone:423-870-1076
Mailing Address - Fax:
Practice Address - Street 1:3641 HIXSON PIKE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-3518
Practice Address - Country:US
Practice Address - Phone:423-870-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional