Provider Demographics
NPI:1861764011
Name:DERRICK, SHANNON METCALF (LPCC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:METCALF
Last Name:DERRICK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E MARKET ST
Mailing Address - Street 2:AFTERCARE PROGRAM
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1838
Mailing Address - Country:US
Mailing Address - Phone:502-596-1323
Mailing Address - Fax:502-596-1416
Practice Address - Street 1:1100 E MARKET ST
Practice Address - Street 2:AFTERCARE PROGRAM
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1838
Practice Address - Country:US
Practice Address - Phone:502-596-1323
Practice Address - Fax:502-596-1416
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional