Provider Demographics
NPI:1821515446
Name:SHANON R. PENNINGTON
Entity Type:Organization
Organization Name:SHANON R. PENNINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:SHANON
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:615-414-8195
Mailing Address - Street 1:125 BREAKWATER BAY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3675
Mailing Address - Country:US
Mailing Address - Phone:615-414-8195
Mailing Address - Fax:
Practice Address - Street 1:125 BREAKWATER BAY
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3675
Practice Address - Country:US
Practice Address - Phone:615-414-8195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1245788116Medicaid