Healthcare Provider Details

I. General information

NPI: 1457169070
Provider Name (Legal Business Name): SHONDA FOUBLASSE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone: 270-798-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number303418
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2138
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: