MEDICARE: SHANA GORDON WALTMAN MA, LCMHC, CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	S7308	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1184802266	OTHER		NPI

General Provider Information

NPI Number	:	1184802266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA GORDON WALTMAN MA, LCMHC, CRC

Provider Business Mailing Address
First Line	:	5 OAK BRANCH DR STE H
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-2157
Country	:	US
Telephone Number	:	336-288-9190
Fax Number	:	336-450-4318

Provider Business Practice Location Address
First Line	:	5 OAK BRANCH DR STE H
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-2157
Country	:	US
Telephone Number	:	336-288-9190
Fax Number	:	336-450-4318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	08/26/2025

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