Provider Demographics
NPI:1811640733
Name:EVANS, SHANTAY SMITH (LPCA)
Entity type:Individual
Prefix:MRS
First Name:SHANTAY
Middle Name:SMITH
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 SANDY PLAINS ROAD
Mailing Address - Street 2:STE 204 PMB 2195
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-7864
Mailing Address - Country:US
Mailing Address - Phone:678-941-9841
Mailing Address - Fax:
Practice Address - Street 1:3552 HABERSHAM AT NORTHLAKE
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4009
Practice Address - Country:US
Practice Address - Phone:678-941-9841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional