Provider Demographics
NPI:1396531091
Name:PANNELL, SHANTA ELIZABETH WARD (MA, QMHP-C)
Entity type:Individual
Prefix:
First Name:SHANTA
Middle Name:ELIZABETH WARD
Last Name:PANNELL
Suffix:
Gender:F
Credentials:MA, QMHP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 LEVEL RUN RD
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND
Mailing Address - State:VA
Mailing Address - Zip Code:24569-2237
Mailing Address - Country:US
Mailing Address - Phone:434-421-9304
Mailing Address - Fax:
Practice Address - Street 1:1555 MEADOWVIEW DR STE 5-6
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-7351
Practice Address - Country:US
Practice Address - Phone:877-848-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0733003038101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health