Basic Information
| Provider Information | |||||||||
| NPI: | 1871723759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LEA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 S CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | LEITCHFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427541492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702594652 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2009 | ||||||||
| LastUpdateDate: | 07/25/2009 | ||||||||
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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 | 0442 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.