Provider Demographics
NPI:1003176363
Name:DALLAS, SHONDA P (LPC)
Entity type:Individual
Prefix:
First Name:SHONDA
Middle Name:P
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 BREEZE MDW
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-6054
Mailing Address - Country:US
Mailing Address - Phone:770-597-9746
Mailing Address - Fax:678-834-5154
Practice Address - Street 1:324 BREEZE MDW
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-6054
Practice Address - Country:US
Practice Address - Phone:770-597-9746
Practice Address - Fax:678-834-5154
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional