Healthcare Provider Details

I. General information

NPI: 1023904158
Provider Name (Legal Business Name): SHEMIKA N ELVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W DYKES ST
COCHRAN GA
31014-6925
US

IV. Provider business mailing address

212 W DYKES ST
COCHRAN GA
31014-6925
US

V. Phone/Fax

Practice location:
  • Phone: 478-230-7932
  • Fax:
Mailing address:
  • Phone: 478-230-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number25114064
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: