Provider Demographics
NPI:1184802266
Name:WALTMAN, SHANA GORDON (MA)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:GORDON
Last Name:WALTMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OAK BRANCH DR STE H
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2157
Mailing Address - Country:US
Mailing Address - Phone:336-288-9190
Mailing Address - Fax:336-450-4318
Practice Address - Street 1:5 OAK BRANCH DR STE H
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2157
Practice Address - Country:US
Practice Address - Phone:336-288-9190
Practice Address - Fax:336-450-4318
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS7308101YP2500X, 101YP2500X
NC00101339225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184802266OtherNPI
NC6104221Medicaid
NC45-5015231OtherTIN