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General NPI Number Information
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NPI Number | 1366181539
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Entity Type | Organization
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Legal Business Name | M SHANNON ENTERPRISES
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Dates
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Enumeration Date | 06/03/2022
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Last Update Date | 05/26/2023
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Provider Practice Location Address
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Address Line | 6900 HOUSTON RD STE 12
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City | FLORENCE
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State | KY
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Zip | 41042-4891
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Country | US
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Telephone | 310-619-8989
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Fax |
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Provider Business Mailing Address
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Address Line | 4375 RIVER RD
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City | HEBRON
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State | KY
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Zip | 41048-9720
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Country | US
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Telephone | 310-619-8989
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JOANNE SELL
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Credential |
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Telephone | 310-993-1329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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