Provider Demographics
NPI:1942802152
Name:HUBBARD, SHANTIL RENEA (MA,QP, LCAS-A)
Entity Type:Individual
Prefix:MS
First Name:SHANTIL
Middle Name:RENEA
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MA,QP, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 COURT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2140
Mailing Address - Country:US
Mailing Address - Phone:704-842-6359
Mailing Address - Fax:
Practice Address - Street 1:2821 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-7701
Practice Address - Country:US
Practice Address - Phone:434-258-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-26865101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)