Healthcare Provider Details

I. General information

NPI: 1760971949
Provider Name (Legal Business Name): SHAWN WHISMAN CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9620 CAREYS RUN POND CREEK RD
MC DERMOTT OH
45652-3902
US

IV. Provider business mailing address

PO BOX 402
WHEELERSBURG OH
45694-0402
US

V. Phone/Fax

Practice location:
  • Phone: 740-858-6683
  • Fax:
Mailing address:
  • Phone: 740-858-6683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCMS
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.175455
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHS
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: