Provider Demographics
NPI:1003354804
Name:HALVERSTADT, SHAWN (LCDC III)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:HALVERSTADT
Suffix:
Gender:M
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 PUEBLO LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-8407
Mailing Address - Country:US
Mailing Address - Phone:330-692-3395
Mailing Address - Fax:
Practice Address - Street 1:49 PUEBLO LN
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-8407
Practice Address - Country:US
Practice Address - Phone:330-692-3395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1211148101YA0400X
PA8291101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)