Provider Demographics
NPI:1922613371
Name:WEIST, SHANNON (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEIST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3395 SIXES RD STE 2202
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 PAPER TRAIL WAY STE 106
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-5204
Practice Address - Country:US
Practice Address - Phone:770-530-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0071081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical