Provider Demographics
NPI:1710488242
Name:STANTON-SHAW, COURTNEY (LPCA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:STANTON-SHAW
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 FARRELL DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3717
Mailing Address - Country:US
Mailing Address - Phone:859-331-3292
Mailing Address - Fax:
Practice Address - Street 1:611 FOREST AVE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-1411
Practice Address - Country:US
Practice Address - Phone:606-564-4016
Practice Address - Fax:606-564-8288
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID