Basic Information
| Provider Information | |||||||||
| NPI: | 1881332666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | SHANNON | ||||||||
| OtherFirstName: | SANDI | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144383400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7 WAVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593854669 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 277873 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.