Healthcare Provider Details

I. General information

NPI: 1154061489
Provider Name (Legal Business Name): DAWN SHANNON CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 ASHLEY CIR STE 5
BOWLING GREEN KY
42104-5803
US

IV. Provider business mailing address

6002 WOODHAVEN PLACE CIR
LOUISVILLE KY
40228-2809
US

V. Phone/Fax

Practice location:
  • Phone: 270-495-1222
  • Fax: 859-209-6504
Mailing address:
  • Phone: 502-876-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6404
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6404
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: