Healthcare Provider Details

I. General information

NPI: 1558607192
Provider Name (Legal Business Name): SHAWNDRA JOVAN ECHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2013
Last Update Date: 01/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

1506 SADDLECREEK DR
MCDONOUGH GA
30253-8931
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2395
  • Fax: 678-990-3997
Mailing address:
  • Phone: 678-756-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: