Provider Demographics
NPI:1538789284
Name:DAVIS KAUFMAN, SHANNON
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:DAVIS KAUFMAN
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:NATIONAL YOUTH ADVOCATE PROGRAM
Mailing Address - Street 2:1020 WOODMAN DRIVE SUITE 330
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432
Mailing Address - Country:US
Mailing Address - Phone:937-496-5464
Mailing Address - Fax:
Practice Address - Street 1:NATIONAL YOUTH ADVOCATE PROGRAM
Practice Address - Street 2:1020 WOODMAN DRIVE SUITE 330
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432
Practice Address - Country:US
Practice Address - Phone:937-253-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161421101YA0400X
OHC.1100468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLCDCIII.161421OtherPROFESSIONAL CHEMICAL DEPENDENCY LICENSE
OHC.1100468OtherPROFESSIONAL COUNSELING LICENSE