MEDICARE: SHAUN MATTHEW BELLERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist
2	175T00000X	Peer Specialist		KY

General Provider Information

NPI Number	:	1295416519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUN MATTHEW BELLERSON

Provider Business Mailing Address
First Line	:	565 HIGHWAY 192 W STE 106
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-2637
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 NEVADA AVE
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-2920
Country	:	US
Telephone Number	:	606-224-7488
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2023
Last Update Date	:	07/28/2023

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Directions to “ SHAUN MATTHEW BELLERSON ” Practice Location

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