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General NPI Number Information
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NPI Number | 1972241131
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Entity Type | Individual
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Provider Name | SHAWN GIBSON LAC, LMSW, LPC
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Gender | Male
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 02/22/2023
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Provider Practice Location Address
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Address Line | 3282 MALLARD COVE LN
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City | FORT WAYNE
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State | IN
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Zip | 46804-2883
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Country | US
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Telephone | 812-558-0574
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Fax |
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Provider Business Mailing Address
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Address Line | 3282 MALLARD COVE LN
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City | FORT WAYNE
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State | IN
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Zip | 46804-2883
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Country | US
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Telephone | 812-558-0574
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 5820
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 13690
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 33010944A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 86000400A
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License Number State | IN
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