Provider Demographics
NPI:1376684571
Name:SHADD, DAVID ALLEN II (LPP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALLEN
Last Name:SHADD
Suffix:II
Gender:M
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PERCY PLACE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324
Mailing Address - Country:US
Mailing Address - Phone:859-229-8543
Mailing Address - Fax:859-255-0749
Practice Address - Street 1:111 NORTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031
Practice Address - Country:US
Practice Address - Phone:859-235-0800
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2004-72103T00000X
KYKY-0110103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY30615058Medicaid