Provider Demographics
NPI:1013691054
Name:WOOTEN, SHANISE
Entity Type:Individual
Prefix:
First Name:SHANISE
Middle Name:
Last Name:WOOTEN
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 1:560 JAKE TRL
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-8617
Mailing Address - Country:US
Mailing Address - Phone:404-834-1001
Mailing Address - Fax:
Practice Address - Street 1:135 BRADFORD SQ STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1902
Practice Address - Country:US
Practice Address - Phone:404-834-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011147104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker