Provider Demographics
NPI:1962108878
Name:LEARY, SHAUNQUISHA
Entity type:Individual
Prefix:
First Name:SHAUNQUISHA
Middle Name:
Last Name:LEARY
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 1:1611 MAJESTY DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-8734
Mailing Address - Country:US
Mailing Address - Phone:252-287-2432
Mailing Address - Fax:
Practice Address - Street 1:288 EAST ST
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-9711
Practice Address - Country:US
Practice Address - Phone:919-704-8449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0178011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC351819323Medicaid