Healthcare Provider Details

I. General information

NPI: 1699214288
Provider Name (Legal Business Name): SHANE SHERIFF LPCC, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WALNUT ST
OWENSBORO KY
42301-2956
US

IV. Provider business mailing address

PO BOX 1637
OWENSBORO KY
42302-1637
US

V. Phone/Fax

Practice location:
  • Phone: 270-689-6598
  • Fax:
Mailing address:
  • Phone: 270-689-6500
  • Fax: 270-689-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number171574
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number268090
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: