Provider Demographics
NPI:1508902628
Name:FENTRESS, SHELLEY M (LPCC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:FENTRESS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:M
Other - Last Name:GREENWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:HC 72 BOX 250
Mailing Address - Street 2:
Mailing Address - City:UNION STAR
Mailing Address - State:KY
Mailing Address - Zip Code:40171-9716
Mailing Address - Country:US
Mailing Address - Phone:270-496-4737
Mailing Address - Fax:
Practice Address - Street 1:107 CRANES ROOST CT
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3650
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:270-234-8572
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0412101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000530500OtherANTHEM
KY30605018Medicaid