Provider Demographics
NPI:1679809016
Name:ELLER, SHANNON M (LPC, CCADC, NCC, CSS)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:ELLER
Suffix:
Gender:F
Credentials:LPC, CCADC, NCC, CSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 N EXPRESSWAY STE B
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1185
Mailing Address - Country:US
Mailing Address - Phone:678-408-4622
Mailing Address - Fax:
Practice Address - Street 1:1815 N EXPRESSWAY STE B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1185
Practice Address - Country:US
Practice Address - Phone:678-408-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPC005894101YP2500X
GAMFT001231106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPC005894OtherPROFESSIONAL LICENSURE BOARD, STATE OF GEORGIA