=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508628827
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANEE WASSON LCMHC-A, LCAS-A
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 SIGNAL HILL DRIVE EXT
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-872-0234
-----------------------------------------------------
Fax | 980-223-8958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 SIGNAL HILL DRIVE EXT
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-872-0234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A18636
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 29541
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------