Provider Demographics
NPI:1740750249
Name:BURNETTE, SHANIQUA CELESS (MS,LCMHC, LCASA, NCC)
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:CELESS
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:MS,LCMHC, LCASA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 LATROBE DR STE 340
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4823
Mailing Address - Country:US
Mailing Address - Phone:704-364-3989
Mailing Address - Fax:
Practice Address - Street 1:3705 LATROBE DR STE 340
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4823
Practice Address - Country:US
Practice Address - Phone:704-364-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCASA25077101YA0400X
NCA14443101YM0800X
NC14443101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265540884Medicaid