Healthcare Provider Details

I. General information

NPI: 1962157131
Provider Name (Legal Business Name): BRIAN SHILTS MS, LMHC, CSAYC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2022
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 SPRINGFIELD AVE
FORT WAYNE IN
46805-1550
US

IV. Provider business mailing address

2632 SPRINGFIELD AVE
FORT WAYNE IN
46805-1550
US

V. Phone/Fax

Practice location:
  • Phone: 260-341-2651
  • Fax:
Mailing address:
  • Phone: 260-341-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88000476A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: