Provider Demographics
NPI:1194950857
Name:DUNLAP, SHANNON K (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:K
Last Name:DUNLAP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 RIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2236
Mailing Address - Country:US
Mailing Address - Phone:706-884-5050
Mailing Address - Fax:706-884-5056
Practice Address - Street 1:610 RIDLEY AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2236
Practice Address - Country:US
Practice Address - Phone:706-884-5050
Practice Address - Fax:706-884-5056
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA202201101YA0400X
GALPC004718101YP2500X
GAPSY003497103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G682008Medicare UPIN