Provider Demographics
NPI:1336814342
Name:SUMNER, SHANE (LCSW)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:SUMNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 MCREES MILL RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2960
Mailing Address - Country:US
Mailing Address - Phone:706-765-7377
Mailing Address - Fax:
Practice Address - Street 1:1091 MCREES MILL RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2960
Practice Address - Country:US
Practice Address - Phone:706-765-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0064841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical