Individual
MRS. SHANTAYIA NEAL PROVOST
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
4595 FLAT WILLOW PL, DOUGLASVILLE, GA 30135-8646
(404) 548-5761
Mailing address
4595 FLAT WILLOW PL, DOUGLASVILLE, GA 30135-8646
(404) 578-5761
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
184759-3102
UT
Other
Enumeration date
06/22/2023
Last updated
06/22/2023
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