Provider Demographics
NPI:1407480577
Name:SHEHANE, MARK (PEER SUPPORTER)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHEHANE
Suffix:
Gender:M
Credentials:PEER SUPPORTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 KENMORE AVE NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-4232
Mailing Address - Country:US
Mailing Address - Phone:330-770-9657
Mailing Address - Fax:
Practice Address - Street 1:5760 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-1170
Practice Address - Country:US
Practice Address - Phone:330-953-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator