Healthcare Provider Details

I. General information

NPI: 1104163625
Provider Name (Legal Business Name): SHADESE LISA GRIFFITH-MCCLELLAN LCSW-A,MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OVERHILL DR STE 105
MOORESVILLE NC
28117-8232
US

IV. Provider business mailing address

1033 PHILLIPS LN
STATESVILLE NC
28625-4747
US

V. Phone/Fax

Practice location:
  • Phone: 980-430-9205
  • Fax: 704-799-8949
Mailing address:
  • Phone: 646-938-9097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-A -21455
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP015291
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: