Provider Demographics
NPI:1396156915
Name:SMITH, SHANNON TENNILLE (MED)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TENNILLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 S HIGHWAY 27 STE 4
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3124
Mailing Address - Country:US
Mailing Address - Phone:606-679-1815
Mailing Address - Fax:606-451-1631
Practice Address - Street 1:3540 S HIGHWAY 27 STE 4
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3124
Practice Address - Country:US
Practice Address - Phone:606-679-1815
Practice Address - Fax:606-451-1631
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0561101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional