Provider Demographics
NPI:1285072470
Name:MOULTRIE-JOHNSON, SHILENE (EDD)
Entity type:Individual
Prefix:DR
First Name:SHILENE
Middle Name:
Last Name:MOULTRIE-JOHNSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 ELI RUN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-3723
Mailing Address - Country:US
Mailing Address - Phone:678-382-4999
Mailing Address - Fax:770-461-4306
Practice Address - Street 1:190 ELI RUN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-3723
Practice Address - Country:US
Practice Address - Phone:678-382-4999
Practice Address - Fax:770-461-4306
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1312032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GATR-BFTS-1397OtherGEORGIA TRAINING APPROVAL:
GA03112367967OtherAMERICAN HEART ASSOCIATION/ BLS INSTRUCTOR
MA1312032OtherTEACHER'S LICENSE