Healthcare Provider Details

I. General information

NPI: 1992342083
Provider Name (Legal Business Name): SHANNAH GARDINER BANION LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2019
Last Update Date: 12/14/2019
Certification Date: 12/14/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 RED HOUSE RD
RICHMOND KY
40475-9326
US

IV. Provider business mailing address

134 ROSE LN
RICHMOND KY
40475-9646
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 859-753-0259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number244649
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: