Provider Demographics
NPI:1326519372
Name:SUTHERLAND, SHANNA M (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:M
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 KENILWORTH PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-2315
Mailing Address - Country:US
Mailing Address - Phone:513-492-2369
Mailing Address - Fax:
Practice Address - Street 1:516 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1626
Practice Address - Country:US
Practice Address - Phone:513-409-3635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1400633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1400633OtherLPC