Provider Demographics
NPI:1982089132
Name:LANG, SHANEEN
Entity Type:Individual
Prefix:
First Name:SHANEEN
Middle Name:
Last Name:LANG
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 1:3161 CUSTER DR STE 4
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4067
Mailing Address - Country:US
Mailing Address - Phone:859-977-6080
Mailing Address - Fax:859-977-4502
Practice Address - Street 1:3161 CUSTER DR STE 4
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4067
Practice Address - Country:US
Practice Address - Phone:859-977-6080
Practice Address - Fax:859-977-4502
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid