Healthcare Provider Details

I. General information

NPI: 1144892647
Provider Name (Legal Business Name): SHANDALE DAWN ALCORN LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 09/13/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 COUNTY HOME ROAD
REIDSVILLE NC
27320
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 336-342-8316
  • Fax: 336-342-8352
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP016512
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: