Provider Demographics
NPI:1720611775
Name:SHORTER, MICHAEL DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SHORTER
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 1:1073 ATHENA CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6867
Mailing Address - Country:US
Mailing Address - Phone:770-853-8561
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW STE 530
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7153
Practice Address - Country:US
Practice Address - Phone:770-376-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW008424101YA0400X, 101YM0800X
GACSW007990101YA0400X, 1041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical