Healthcare Provider Details

I. General information

NPI: 1164708228
Provider Name (Legal Business Name): SHANNON KERSEY, LPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 RANDOLPH RD SUITE 208
CHARLOTTE NC
28211-2351
US

IV. Provider business mailing address

4425 RANDOLPH RD SUITE 208
CHARLOTTE NC
28211-2351
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-6586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2531
License Number StateNC

VIII. Authorized Official

Name: MS. SHANNON KERSEY
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 704-323-6586