Provider Demographics
NPI:1649708462
Name:GOLLNER, SHANNON (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GOLLNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 MARYANNE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7420
Mailing Address - Country:US
Mailing Address - Phone:1618-308-0310
Mailing Address - Fax:
Practice Address - Street 1:201 PHILLIPS CT
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3772
Practice Address - Country:US
Practice Address - Phone:270-683-6481
Practice Address - Fax:270-926-0817
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1005251S00000X
KY2526401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health