Basic Information
| Provider Information | |||||||||
| NPI: | 1265983332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIVELY | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAILEY | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | MLC 3014 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364788 | ||||||||
| FaxNumber: | 5136364283 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | MLC 3014 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364788 | ||||||||
| FaxNumber: | 5136364283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E.0500031 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.