Basic Information
| Provider Information | |||||||||
| NPI: | 1578609368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENT | ||||||||
| FirstName: | SHAWNTA | ||||||||
| MiddleName: | DYNISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW, LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | SHAWNTA | ||||||||
| OtherMiddleName: | DYNISE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSW, PC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1490 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450113305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138967887 | ||||||||
| FaxNumber: | 5138965682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821 SUMMIT RD | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452372822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139480023 | ||||||||
| FaxNumber: | 5139480087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 11/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S23628 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 101YP2500X | E0008428 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.