Basic Information
| Provider Information | |||||||||
| NPI: | 1508902628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENTRESS | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENWELL | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPCC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | HC 72 BOX 250 | ||||||||
| Address2: | |||||||||
| City: | UNION STAR | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401719716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704964737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 11/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | KY-0412 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000000530500 | 01 | KY | ANTHEM | OTHER | 30605018 | 05 | KY | MEDICAID |