1669966685 NPI number — SHAWN S ALDRIDGE LICDC

Table of content: SHAWN S ALDRIDGE LICDC (NPI 1669966685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669966685 NPI number — SHAWN S ALDRIDGE LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALDRIDGE
Provider First Name:
SHAWN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669966685
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17618 STATE ROUTE 93
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEDRO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45659-8754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-646-5753
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11826 GALLIA PIKE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEELERSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45694-9119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-876-4117
Provider Business Practice Location Address Fax Number:
800-480-7578
Provider Enumeration Date:
06/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LICDC.162867 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0342311 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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