Provider Demographics
NPI:1306370887
Name:FAGON, SHAWNA-GAYE (LPC, NCC)
Entity type:Individual
Prefix:MISS
First Name:SHAWNA-GAYE
Middle Name:
Last Name:FAGON
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SHADOWHILL LN
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8289
Mailing Address - Country:US
Mailing Address - Phone:404-825-9705
Mailing Address - Fax:
Practice Address - Street 1:270 CARPENTER DR
Practice Address - Street 2:SUITE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4931
Practice Address - Country:US
Practice Address - Phone:678-460-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009436251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health