Provider Demographics
NPI:1124626643
Name:BASSETT, SHANA EVANS (MS, MED, APC)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:EVANS
Last Name:BASSETT
Suffix:
Gender:F
Credentials:MS, MED, APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 N HIGHLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3314
Mailing Address - Country:US
Mailing Address - Phone:678-360-3429
Mailing Address - Fax:
Practice Address - Street 1:6 LENOX POINTE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3167
Practice Address - Country:US
Practice Address - Phone:404-735-9039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007599101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional