Provider Demographics
NPI:1851153431
Name:BENNETT, SHANNON RAY (CPSS,CSA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CPSS,CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 CUMBERLAND FALLS HWY
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-9056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3444 CUMBERLAND FALLS HWY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-9056
Practice Address - Country:US
Practice Address - Phone:606-280-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist