Provider Demographics
NPI:1720596091
Name:CRASE, SHANNON KAY
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAY
Last Name:CRASE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:NUTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N MILES ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1834
Practice Address - Country:US
Practice Address - Phone:270-506-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00005127106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician