Provider Demographics
NPI:1679870646
Name:O'SHAUGHNESSY, STEPHEN MICHAEL
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:O'SHAUGHNESSY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 ROLSTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1535
Mailing Address - Country:US
Mailing Address - Phone:260-609-3360
Mailing Address - Fax:
Practice Address - Street 1:3407 ROLSTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1535
Practice Address - Country:US
Practice Address - Phone:260-609-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000019A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist