Provider Demographics
NPI:1336941947
Name:TOLLIVER, SHAUNA MOORE (LCSWA)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:MOORE
Last Name:TOLLIVER
Suffix:
Gender:
Credentials:LCSWA
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:LEE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSWA
Mailing Address - Street 1:2900 MARANVILLE TRL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-4448
Mailing Address - Country:US
Mailing Address - Phone:336-409-5581
Mailing Address - Fax:
Practice Address - Street 1:2900 MARANVILLE TRL
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-4448
Practice Address - Country:US
Practice Address - Phone:336-409-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP016015104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker