Provider Demographics
NPI:1386354140
Name:PROWELL, SHANEKA LYNETTE
Entity type:Individual
Prefix:
First Name:SHANEKA
Middle Name:LYNETTE
Last Name:PROWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 ALPINE VLG APT C
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-5936
Mailing Address - Country:US
Mailing Address - Phone:205-914-5137
Mailing Address - Fax:
Practice Address - Street 1:2008 21ST STREET ENSLEY
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35218-2963
Practice Address - Country:US
Practice Address - Phone:205-224-4387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04343101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty