Provider Demographics
NPI:1356058531
Name:COPENHAVER, SHANNON PITTS
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:PITTS
Last Name:COPENHAVER
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 1:3549 CARRIAGE FARM RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-8244
Mailing Address - Country:US
Mailing Address - Phone:919-457-6970
Mailing Address - Fax:
Practice Address - Street 1:3201 NASH ST NW STE A
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-3000
Practice Address - Country:US
Practice Address - Phone:252-289-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18166101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health