Provider Demographics
NPI:1972241131
Name:GIBSON, SHAWN (LAC, LMSW, LPC)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LAC, LMSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3282 MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:812-558-0574
Mailing Address - Fax:
Practice Address - Street 1:3282 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2883
Practice Address - Country:US
Practice Address - Phone:812-558-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5820101YP2500X
TN13690104100000X
IN33010944A104100000X
IN86000400A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker