Provider Demographics
NPI:1225895428
Name:PEGRAM, SHAPELL
Entity Type:Individual
Prefix:
First Name:SHAPELL
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3934 DIXIE HWY STE 330
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4170
Mailing Address - Country:US
Mailing Address - Phone:502-409-4357
Mailing Address - Fax:
Practice Address - Street 1:3934 DIXIE HWY STE 330
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4170
Practice Address - Country:US
Practice Address - Phone:502-409-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health