Provider Demographics
NPI:1770573990
Name:BEAN, SHAVONDA LATIEA (MA, LPA)
Entity type:Individual
Prefix:MRS
First Name:SHAVONDA
Middle Name:LATIEA
Last Name:BEAN
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Gender:F
Credentials:MA, LPA
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Mailing Address - Street 1:8430 UNIVERSITY EXEC PARK DR
Mailing Address - Street 2:SUITE 655
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1350
Mailing Address - Country:US
Mailing Address - Phone:704-596-5553
Mailing Address - Fax:704-596-1556
Practice Address - Street 1:8430 UNIVERSITY EXEC PARK DR
Practice Address - Street 2:SUITE 655
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1350
Practice Address - Country:US
Practice Address - Phone:704-596-5553
Practice Address - Fax:704-596-1556
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2013-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC2477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2118431OtherCIGNA
NCE4167-B0775OtherMEDCOST
NC046KTOtherBCBS
NC6107067Medicaid