Healthcare Provider Details

I. General information

NPI: 1366181539
Provider Name (Legal Business Name): M SHANNON ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 HOUSTON RD STE 12
FLORENCE KY
41042-4891
US

IV. Provider business mailing address

4375 RIVER RD
HEBRON KY
41048-9720
US

V. Phone/Fax

Practice location:
  • Phone: 310-619-8989
  • Fax:
Mailing address:
  • Phone: 310-619-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JOANNE SELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-993-1329