Healthcare Provider Details

I. General information

NPI: 1356529754
Provider Name (Legal Business Name): SHAY LYNN SWAN MS QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAY FARNER

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

9230 MANEESE LN
GOREVILLE IL
62939-3612
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax: 618-658-2501
Mailing address:
  • Phone: 618-713-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: