Provider Demographics
NPI:1821034646
Name:SHANAHAN, TAMMY (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 W WALNUT ST
Mailing Address - Street 2:PO BOX 484
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2223
Mailing Address - Country:US
Mailing Address - Phone:270-251-3666
Mailing Address - Fax:270-251-3506
Practice Address - Street 1:229 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2223
Practice Address - Country:US
Practice Address - Phone:270-251-3666
Practice Address - Fax:270-251-3506
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1775101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY82000613Medicaid
KY82000613Medicaid