Provider Demographics
NPI:1437510005
Name:RUSSELL, SHANNON (LBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1008
Mailing Address - Country:US
Mailing Address - Phone:502-409-7181
Mailing Address - Fax:888-450-0935
Practice Address - Street 1:1519 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1008
Practice Address - Country:US
Practice Address - Phone:502-409-7181
Practice Address - Fax:888-450-0935
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYABALBA00225141103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst