Provider Demographics
NPI:1689066946
Name:THACKER, SHAWNA (CADC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1522
Mailing Address - Country:US
Mailing Address - Phone:606-437-0047
Mailing Address - Fax:606-437-0547
Practice Address - Street 1:368 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1522
Practice Address - Country:US
Practice Address - Phone:606-437-0047
Practice Address - Fax:606-437-0547
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYADCADC00216716101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator