Provider Demographics
NPI:1649634965
Name:GARY, SHANA (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:GARY
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 OLIVERS CROSSING CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-7164
Mailing Address - Country:US
Mailing Address - Phone:336-251-5796
Mailing Address - Fax:
Practice Address - Street 1:4035 UNIVERSITY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3275
Practice Address - Country:US
Practice Address - Phone:336-397-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0102931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical