Provider Demographics
NPI:1487429601
Name:MOFFETT-SMITH, SHANTONIA (CAPSW, LSW)
Entity type:Individual
Prefix:
First Name:SHANTONIA
Middle Name:
Last Name:MOFFETT-SMITH
Suffix:
Gender:F
Credentials:CAPSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1236
Mailing Address - Country:US
Mailing Address - Phone:318-605-9046
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TERRACE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1346281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical