MEDICARE: MRS. SHAWNTA DYNISE BRENT LSW, LPCC

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	104100000X	Social Worker	S23628	OH
2	101YP2500X	Professional Counselor	E0008428	OH

General Provider Information

NPI Number	:	1578609368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHAWNTA DYNISE BRENT LSW, LPCC

Provider Business Mailing Address
First Line	:	1490 UNIVERSITY BLVD
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45011-3305
Country	:	US
Telephone Number	:	513-896-7887
Fax Number	:	513-896-5682

Provider Business Practice Location Address
First Line	:	1821 SUMMIT RD
Second Line	:	SUITE 216
City	:	CINCINNATI
State	:	OH
Zip	:	45237-2822
Country	:	US
Telephone Number	:	513-948-0023
Fax Number	:	513-948-0087

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	11/23/2009

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