Provider Demographics
NPI:1386998169
Name:FRYSON, SHANTAE NICOLE (MSW, LSW)
Entity type:Individual
Prefix:MRS
First Name:SHANTAE
Middle Name:NICOLE
Last Name:FRYSON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 SYCAMORE LINE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4132
Mailing Address - Country:US
Mailing Address - Phone:419-626-9156
Mailing Address - Fax:419-621-0099
Practice Address - Street 1:1634 SYCAMORE LINE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-626-9156
Practice Address - Fax:419-621-0099
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS600034104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2325906Medicaid