Healthcare Provider Details

I. General information

NPI: 1043930332
Provider Name (Legal Business Name): SHAUN ALEXANDER HARDIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 STONEY CREEK DR
FORT WAYNE IN
46825-4401
US

IV. Provider business mailing address

5933 STONEY CREEK DR 5933 STONEY CREEK DR
FORT WAYNE IN
46825-4401
US

V. Phone/Fax

Practice location:
  • Phone: 260-207-4861
  • Fax:
Mailing address:
  • Phone: 260-207-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: