Provider Demographics
NPI:1720789118
Name:HERVEY, SHANNON DEMETRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:DEMETRE
Last Name:HERVEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1551
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1551
Mailing Address - Country:US
Mailing Address - Phone:678-313-4899
Mailing Address - Fax:
Practice Address - Street 1:751 TEMPLETON DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5666
Practice Address - Country:US
Practice Address - Phone:678-313-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
GACSW0032921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool