Provider Demographics
NPI:1285206656
Name:SHATTERED 2 RESTORED
Entity Type:Organization
Organization Name:SHATTERED 2 RESTORED
Other - Org Name:SHATTERED 2 RESTORED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHENEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:270-875-2548
Mailing Address - Street 1:7659 MALL RD # 1016
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1403
Mailing Address - Country:US
Mailing Address - Phone:859-379-8152
Mailing Address - Fax:
Practice Address - Street 1:7659 MALL RD # 1016
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1403
Practice Address - Country:US
Practice Address - Phone:859-379-8152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty