Provider Information for 1649708462
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SHANNON GOLLNER LCSW
Sex: Female
NPI: 1649708462
Last Updated: 2018-03-17
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||
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| NPI | 1649708462 | ||||||||||||
| Enumeration Date | 2017-05-24 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 1760 MARYANNE RD SHOW LOW, AZ 85901-7420 United States Phone: 16183080310 | Fax: | ||||||||||||
| Primary Practice Address | 201 PHILLIPS CT OWENSBORO, KY 42303-3772 United States Phone: 270-683-6481 | Fax:270-926-0817 | ||||||||||||
| Secondary Practice Address(es) | 1100 WALNUT ST | ||||||||||||
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