Provider Demographics
NPI:1215427752
Name:SHIVELY, MARIANA BRADY (MA, LPC, RPT)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:BRADY
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:MA, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 WOODGLEN DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3726
Mailing Address - Country:US
Mailing Address - Phone:305-812-6610
Mailing Address - Fax:
Practice Address - Street 1:220 OAKSIDE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6413
Practice Address - Country:US
Practice Address - Phone:678-807-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006304101YM0800X
GALPC011898101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health