Healthcare Provider Details

I. General information

NPI: 1518415561
Provider Name (Legal Business Name): SHANA LEIGH GOGGINS MA, LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

944 RED HOUSE RD
RICHMOND KY
40475-9392
US

IV. Provider business mailing address

1939 GOLDSMITH LN SUITE 143
LOUISVILLE KY
40218-2006
US

V. Phone/Fax

Practice location:
  • Phone: 502-252-1865
  • Fax: 502-631-9660
Mailing address:
  • Phone: 502-252-1865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number170710
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: