Healthcare Provider Details

I. General information

NPI: 1699293985
Provider Name (Legal Business Name): SHANE FERRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 TENNESSEE AVE
FORT CAMPBELL KY
42223-5928
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 270-461-0570
  • Fax:
Mailing address:
  • Phone: 912-435-6965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006219
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: