MEDICARE: JOHN SHEALY LISW, LICDC-CS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	I0018420SUPV	OH
2	101YM0800X	Mental Health Counselor	I0018420SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508209834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN SHEALY LISW, LICDC-CS

Provider Business Mailing Address
First Line	:	118 STOVER DR
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-8601
Country	:	US
Telephone Number	:	740-369-6811
Fax Number	:	740-363-8742

Provider Business Practice Location Address
First Line	:	118 STOVER DR
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-8601
Country	:	US
Telephone Number	:	740-369-6811
Fax Number	:	740-363-8742

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2013
Last Update Date	:	04/17/2013

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