Healthcare Provider Details

I. General information

NPI: 1275494098
Provider Name (Legal Business Name): SHANNON SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 FISK CT
LEXINGTON KY
40511-8369
US

IV. Provider business mailing address

1016 FISK CT
LEXINGTON KY
40511-8369
US

V. Phone/Fax

Practice location:
  • Phone: 859-358-2520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW00001174
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: