Provider Demographics
NPI:1104604347
Name:REID, SHAWNETTE
Entity type:Individual
Prefix:
First Name:SHAWNETTE
Middle Name:
Last Name:REID
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 1:106 FOUNDERS APT 103
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-4589
Mailing Address - Country:US
Mailing Address - Phone:757-292-1014
Mailing Address - Fax:
Practice Address - Street 1:2200 EXECUTIVE DR STE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2582
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0709024824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)