Basic Information
| Provider Information | |||||||||
| NPI: | 1669966685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALDRIDGE | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 MARION PIKE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 MARION PIKE STE 3 | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
| FaxNumber: | 8664757263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2018 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.169930 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0298114 | 05 | OH | MEDICAID |