Provider Demographics
NPI:1609698794
Name:GHOLSTON, SHAUNA PADGETT (M ED)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:PADGETT
Last Name:GHOLSTON
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 LEMONTREE LN
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-5252
Mailing Address - Country:US
Mailing Address - Phone:314-669-1498
Mailing Address - Fax:
Practice Address - Street 1:1991 LEMONTREE LN
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-5252
Practice Address - Country:US
Practice Address - Phone:314-669-1498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist