Healthcare Provider Details

I. General information

NPI: 1669305587
Provider Name (Legal Business Name): KINDRALL D SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 FELTON AVE APT B16
MACON GA
31201-2496
US

IV. Provider business mailing address

2111 FELTON AVE APT B16
MACON GA
31201-2496
US

V. Phone/Fax

Practice location:
  • Phone: 479-361-4280
  • Fax: 479-361-4280
Mailing address:
  • Phone: 478-361-4280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: