Provider Demographics
NPI:1619926615
Name:SHAFFER, MICHAEL WAYNE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:WAYNE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:113 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:GAS CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46933-1138
Mailing Address - Country:US
Mailing Address - Phone:765-674-3321
Mailing Address - Fax:765-677-5115
Practice Address - Street 1:1700 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4568
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:765-677-5115
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20854101YA0400X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical