MEDICARE: STEPHEN MICHAEL O'SHAUGHNESSY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	85000019A	IN

General Provider Information

NPI Number	:	1679870646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN MICHAEL O'SHAUGHNESSY

Provider Business Mailing Address
First Line	:	3407 ROLSTON ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1535
Country	:	US
Telephone Number	:	260-609-3360
Fax Number	:

Provider Business Practice Location Address
First Line	:	3407 ROLSTON ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1535
Country	:	US
Telephone Number	:	260-609-3360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2011
Last Update Date	:	02/27/2011

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