Provider Demographics
NPI:1255148110
Name:AMBURGEY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:AMBURGEY
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 1:430 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:44836-9734
Mailing Address - Country:US
Mailing Address - Phone:419-707-9498
Mailing Address - Fax:
Practice Address - Street 1:430 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9734
Practice Address - Country:US
Practice Address - Phone:419-707-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-14
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.188466101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)