Healthcare Provider Details

I. General information

NPI: 1740192632
Provider Name (Legal Business Name): SHARDASIA SURLES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9008 ASHFORD CT
FAIRBURN GA
30213-4746
US

IV. Provider business mailing address

9008 ASHFORD CT
FAIRBURN GA
30213-4746
US

V. Phone/Fax

Practice location:
  • Phone: 334-412-2575
  • Fax:
Mailing address:
  • Phone: 334-412-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSW011807
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: