Provider Demographics
NPI:1619987641
Name:MATTINGLY, SHAUNA (LCSW)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0610
Mailing Address - Country:US
Mailing Address - Phone:912-286-2423
Mailing Address - Fax:
Practice Address - Street 1:1520 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0610
Practice Address - Country:US
Practice Address - Phone:912-286-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0036621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80BBHJXMedicare PIN
GA80BBGLSMedicare PIN