Healthcare Provider Details

I. General information

NPI: 1104487297
Provider Name (Legal Business Name): SHAKEYLIEA ROBINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MADISON AVE
COVINGTON KY
41011-3369
US

IV. Provider business mailing address

1450 MADISON AVE
COVINGTON KY
41011-3369
US

V. Phone/Fax

Practice location:
  • Phone: 859-444-4499
  • Fax:
Mailing address:
  • Phone: 859-444-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number174942
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: