Healthcare Provider Details

I. General information

NPI: 1376684571
Provider Name (Legal Business Name): DAVID ALLEN SHADD II LPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/11/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 W LOUDON AVE
LEXINGTON KY
40508-3729
US

IV. Provider business mailing address

360 W LOUDON AVE
LEXINGTON KY
40508-3729
US

V. Phone/Fax

Practice location:
  • Phone: 859-252-7881
  • Fax: 859-255-0749
Mailing address:
  • Phone: 859-229-8543
  • Fax: 859-255-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberKY-115960
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: