Provider Demographics
NPI:1023334984
Name:CORDSEN, SHELLY WONG (LPC)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:WONG
Last Name:CORDSEN
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0454
Mailing Address - Country:US
Mailing Address - Phone:678-404-0112
Mailing Address - Fax:
Practice Address - Street 1:11 LUMPKIN ST STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8451
Practice Address - Country:US
Practice Address - Phone:678-404-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005306101YP2500X, 101YM0800X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst