Healthcare Provider Details

I. General information

NPI: 1639885353
Provider Name (Legal Business Name): SHELBIE MONIQUE BOSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 ENTERPRISE PATH
HIRAM GA
30141-2656
US

IV. Provider business mailing address

101 QUARTZ DR STE 103A
VILLA RICA GA
30180-3201
US

V. Phone/Fax

Practice location:
  • Phone: 678-567-0920
  • Fax:
Mailing address:
  • Phone: 770-812-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC017543
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: