Provider Demographics
NPI:1730834532
Name:PARKER, SHANITA MITCHELL (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SHANITA
Middle Name:MITCHELL
Last Name:PARKER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10932 TAVERNAY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4435
Mailing Address - Country:US
Mailing Address - Phone:703-399-5146
Mailing Address - Fax:
Practice Address - Street 1:10932 TAVERNAY PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4435
Practice Address - Country:US
Practice Address - Phone:703-399-5146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0121641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC012164OtherLCSW
NCC012164Medicaid