Healthcare Provider Details

I. General information

NPI: 1477126340
Provider Name (Legal Business Name): SHYANNA KIRBY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHYANNA VANMETER LSW

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 EBERHART AVE
EDWARDSVILLE IL
62025-1013
US

IV. Provider business mailing address

1400 EBERHART AVE
EDWARDSVILLE IL
62025-1013
US

V. Phone/Fax

Practice location:
  • Phone: 217-871-1089
  • Fax:
Mailing address:
  • Phone: 217-871-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150105411
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.026648
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: