Provider Demographics
NPI:1417090168
Name:NOTTINGHAM, SHANNON RYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RYAN
Last Name:NOTTINGHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-9409
Mailing Address - Country:US
Mailing Address - Phone:270-288-5036
Mailing Address - Fax:270-288-5082
Practice Address - Street 1:1118 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-9409
Practice Address - Country:US
Practice Address - Phone:270-288-5036
Practice Address - Fax:270-288-5082
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2558671041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid