Provider Demographics
NPI:1659719417
Name:SHOEMAKER, JUSTIN DWIGHT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DWIGHT
Last Name:SHOEMAKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6366
Mailing Address - Country:US
Mailing Address - Phone:309-797-2900
Mailing Address - Fax:
Practice Address - Street 1:2100 52ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6366
Practice Address - Country:US
Practice Address - Phone:309-797-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0157961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical