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General NPI Number Information
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NPI Number | 1346436524
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Entity Type | Individual
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Provider Name | SHANNON RAE RECUPERO LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/20/2007
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Last Update Date | 04/01/2024
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Provider Practice Location Address
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Address Line | 300 W HOSPITAL RD ROOM 13A-10
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City | FORT GORDON
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State | GA
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Zip | 30905-5741
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Country | US
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Telephone | 706-787-9054
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Fax | 706-787-8991
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Provider Business Mailing Address
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Address Line | 300 E HOSPITAL RD ROOM 13A-10
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City | FORT GORDON
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State | GA
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Zip | 30905-5650
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Country | US
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Telephone | 706-787-9054
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Fax | 706-787-8991
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW003777
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License Number State | GA
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