Provider Demographics
NPI:1790557122
Name:MOELLER, SHANNON SMITH (LPCA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:SMITH
Last Name:MOELLER
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 1:228 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1330
Mailing Address - Country:US
Mailing Address - Phone:804-517-9640
Mailing Address - Fax:
Practice Address - Street 1:105 S HAMILTON ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1607
Practice Address - Country:US
Practice Address - Phone:502-642-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY279690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health