Provider Demographics
NPI:1730616004
Name:MOBLEY-TAYLOR, SHANDA MARIE (LPC)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:MARIE
Last Name:MOBLEY-TAYLOR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AUTUMN DR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5675
Mailing Address - Country:US
Mailing Address - Phone:912-667-8806
Mailing Address - Fax:
Practice Address - Street 1:5805 HIGHWAY 21 S STE 18-19
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5511
Practice Address - Country:US
Practice Address - Phone:912-667-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional