=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750858189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON R SHADIX LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 04/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 MILLARD FARMER IND BLVD
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30263-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-854-6625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 STURGESS RUN
-----------------------------------------------------
City | SHARPSBURG
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30277-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-249-1025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC010552
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------