Provider Demographics
NPI:1063693810
Name:SELLERS-HARTY, SHANNON (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:SELLERS-HARTY
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 1:717 GREEN VALLEY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-2156
Mailing Address - Country:US
Mailing Address - Phone:336-686-5838
Mailing Address - Fax:336-346-2975
Practice Address - Street 1:301 STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-5942
Practice Address - Country:US
Practice Address - Phone:336-686-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0062731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007342Medicaid
NCQ40586AOtherMEDICARE PTAN