Provider Demographics
NPI:1841871118
Name:PERRY-SAMUELS, SHANELL
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:PERRY-SAMUELS
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 1:3942 COTTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-4156
Mailing Address - Country:US
Mailing Address - Phone:336-596-7058
Mailing Address - Fax:
Practice Address - Street 1:418B W MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2534
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:888-261-6694
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician