Provider Demographics
NPI:1104481035
Name:TRUESDALE-EL, SHAVIA
Entity type:Individual
Prefix:
First Name:SHAVIA
Middle Name:
Last Name:TRUESDALE-EL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-4837
Mailing Address - Country:US
Mailing Address - Phone:434-222-4610
Mailing Address - Fax:
Practice Address - Street 1:324 VALLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4837
Practice Address - Country:US
Practice Address - Phone:434-222-4610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional