Provider Demographics
NPI:1700473469
Name:ANDERSON, SHELBY LEA
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEA
Last Name:ANDERSON
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 1:2041 BERKLEY HALL WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-0036
Mailing Address - Country:US
Mailing Address - Phone:907-982-7704
Mailing Address - Fax:
Practice Address - Street 1:1122 SAM NEWELL RD STE 103
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5016
Practice Address - Country:US
Practice Address - Phone:980-202-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP014824101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health