Healthcare Provider Details

I. General information

NPI: 1407718257
Provider Name (Legal Business Name): SHAKEENA STOTRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 WAKEFIELD MOUND RD
PIKETON OH
45661-9660
US

IV. Provider business mailing address

2266 WAKEFIELD MOUND RD
PIKETON OH
45661-9660
US

V. Phone/Fax

Practice location:
  • Phone: 740-351-9298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194318
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: