Provider Demographics
NPI:1932857158
Name:MCDUFFIE, SHANIQUA
Entity Type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:
Last Name:MCDUFFIE
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 1:2540 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1990
Mailing Address - Country:US
Mailing Address - Phone:614-602-6476
Mailing Address - Fax:614-953-2802
Practice Address - Street 1:2540 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1990
Practice Address - Country:US
Practice Address - Phone:614-602-6476
Practice Address - Fax:614-953-2802
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician