Healthcare Provider Details

I. General information

NPI: 1316636418
Provider Name (Legal Business Name): SHANNON GARY LOVETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2466 CARNES ROAD
JONESBORO GA
30236
US

IV. Provider business mailing address

2466 CARNES ROAD
JONESBORO GA
30236
US

V. Phone/Fax

Practice location:
  • Phone: 470-491-3838
  • Fax:
Mailing address:
  • Phone: 470-491-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013806
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: