Healthcare Provider Details

I. General information

NPI: 1962966010
Provider Name (Legal Business Name): SHANNON NAKEAYVA MINES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23331 DABNEY MILL RD
NORTH DINWIDDIE VA
23803-9101
US

IV. Provider business mailing address

23331 DABNEY MILL RD
NORTH DINWIDDIE VA
23803-9101
US

V. Phone/Fax

Practice location:
  • Phone: 804-837-0630
  • Fax: 804-469-4944
Mailing address:
  • Phone: 804-837-0630
  • Fax: 804-469-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701008071.
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: