Provider Demographics
NPI:1073881744
Name:BAILEY, SHANNON DALE (MA, LCADC, CCS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DALE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MA, LCADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EASTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9797
Mailing Address - Country:US
Mailing Address - Phone:502-866-0664
Mailing Address - Fax:502-866-0666
Practice Address - Street 1:105 EASTSIDE DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9797
Practice Address - Country:US
Practice Address - Phone:502-866-0664
Practice Address - Fax:502-866-0666
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY168771OtherLCADC
KY80236Medicaid