Provider Demographics
NPI:1770913436
Name:GAMBILL, SHANNON (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:GAMBILL
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 1:2536 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1949
Mailing Address - Country:US
Mailing Address - Phone:502-649-6864
Mailing Address - Fax:
Practice Address - Street 1:4010 DUPONT CIR STE 582
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4888
Practice Address - Country:US
Practice Address - Phone:502-899-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-17
Last Update Date:2013-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical