Provider Demographics
NPI:1760971949
Name:WHISMAN, SHAWN (CDCA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:WHISMAN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-0402
Mailing Address - Country:US
Mailing Address - Phone:740-858-6683
Mailing Address - Fax:
Practice Address - Street 1:9620 CAREYS RUN POND CREEK RD
Practice Address - Street 2:
Practice Address - City:MC DERMOTT
Practice Address - State:OH
Practice Address - Zip Code:45652-3902
Practice Address - Country:US
Practice Address - Phone:740-858-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CMS171M00000X
OHCDCA.175455101YA0400X
QMHS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0353740Medicaid