Provider Demographics
NPI:1497016786
Name:BERNTSON, SHANNAN LEIGH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:LEIGH
Last Name:BERNTSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:LEIGH
Other - Last Name:HOFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3345 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-8204
Mailing Address - Country:US
Mailing Address - Phone:928-580-0609
Mailing Address - Fax:
Practice Address - Street 1:2141 OLD ASHLAND CITY RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-553-8500
Practice Address - Fax:931-553-8544
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-03
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN62211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027454Medicaid