Provider Demographics
NPI:1134630577
Name:SHANNON, MELANIE R
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:R
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6900 HOUSTON RD STE 12
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4891
Practice Address - Country:US
Practice Address - Phone:310-619-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY259926101YM0800X, 101YP2500X
OHC.1700453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY259926OtherLICENSURE
OHC.1700453OtherLICENSURE