MEDICARE: SHELLEY MAYS-COUCH LCSW

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	101YM0800X	Mental Health Counselor	0904009536	VA
2	101YP1600X	Pastoral Counselor	0904009536	VA
3	101YP2500X	Professional Counselor	0904009536	VA
4	1041C0700X	Clinical Social Worker	0904009536	VA

General Provider Information

NPI Number	:	1821547639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY MAYS-COUCH LCSW

Provider Business Mailing Address
First Line	:	PO BOX 37
Second Line	:
City	:	FARMVILLE
State	:	VA
Zip	:	23901-0037
Country	:	US
Telephone Number	:	434-547-2545
Fax Number	:	855-843-9298

Provider Business Practice Location Address
First Line	:	1839 THOMAS JEFFERSON HWY
Second Line	:
City	:	CHARLOTTE COURT HOUSE
State	:	VA
Zip	:	23923-3818
Country	:	US
Telephone Number	:	434-547-2545
Fax Number	:	855-843-9298

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

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	07/21/2022

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