Basic Information
| Provider Information | |||||||||
| NPI: | 1689954232 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOREHEAD STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | MOREHEAD STATE UNIVERSITY COUNSEL & HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 ALLIE YOUNG HALL | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067832885 | ||||||||
| FaxNumber: | 6067839106 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 ALLIE YOUNG HALL | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067832885 | ||||||||
| FaxNumber: | 6067839106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2011 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6067832123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOREHEAD STATE UNIVERSITY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DNP, APRN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0668 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | 03203 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | 3796P | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3002104 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1041C0700X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YP2500X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 363L00000X | 3004857 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000609845 | 01 | KY | ANTHEM BCBS | OTHER | 000000623843 | 01 | KY | ANTHEM BCBS | OTHER | P00754288 | 01 | KY | RR MEDICARE | OTHER | 2973242 | 05 | OH | MEDICAID | 30610026 | 05 | KY | MEDICAID | K021100 | 01 | KY | MEDICARE GROUP | OTHER | 000000231892 | 01 | ANTHEM BCBS | OTHER | 2826311 | 05 | OH | MEDICAID | 7100092610 | 05 | KY | MEDICAID | 000000298213 | 01 | KY | ANTHEM BCBS | OTHER | 7100034230 | 05 | KY | MEDICAID | 78010220 | 05 | KY | MEDICAID |