Provider Demographics
NPI:1992535066
Name:O'CARROLL, SHANNON (APC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'CARROLL
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 RUDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2952
Mailing Address - Country:US
Mailing Address - Phone:678-982-5516
Mailing Address - Fax:
Practice Address - Street 1:201 FORREST AVE STE 201-B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3222
Practice Address - Country:US
Practice Address - Phone:678-982-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional