Provider Demographics
NPI:1316449572
Name:MOODY, SHAMARA (LPC, DCC)
Entity type:Individual
Prefix:
First Name:SHAMARA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LPC, DCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 GEORGIA AVE E UNIT 1854
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5519
Mailing Address - Country:US
Mailing Address - Phone:404-408-7483
Mailing Address - Fax:
Practice Address - Street 1:245 COUNTRY CLUB DR BLDG 100D
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7216
Practice Address - Country:US
Practice Address - Phone:404-408-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009502101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional