Healthcare Provider Details

I. General information

NPI: 1386481745
Provider Name (Legal Business Name): SHANNON SHANTEL BOYD LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 YELLOW JACKET LN
BESSEMER CITY NC
28016-2778
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-836-9601
  • Fax: 704-629-2775
Mailing address:
  • Phone: 704-874-1907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP020784
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: