Provider Demographics
NPI:1679243315
Name:SWINNEY, SHANNON ROSE (LPP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:SWINNEY
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:SHAUGHNESSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10401 LINN STATION RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3842
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:502-589-8745
Practice Address - Street 1:11103 PARK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2424
Practice Address - Country:US
Practice Address - Phone:502-245-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY629848103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist