Provider Demographics
NPI:1336167576
Name:SHADDEN, MILLICENT JOHNSON (LCSW)
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:JOHNSON
Last Name:SHADDEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:M
Other - Middle Name:MICHELE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-718-3550
Practice Address - Fax:336-277-6981
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0019021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106234Medicaid
2878966AMedicare ID - Type Unspecified