Provider Demographics
NPI:1033468525
Name:BENNINGFIELD, SHAWN THOMAS (LPCC)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:THOMAS
Last Name:BENNINGFIELD
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9702 STONESTREET RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-6812
Mailing Address - Country:US
Mailing Address - Phone:502-749-6249
Mailing Address - Fax:
Practice Address - Street 1:9702 STONESTREET RD STE 120
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272
Practice Address - Country:US
Practice Address - Phone:502-749-6249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY165330101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100527100Medicaid