Provider Demographics
NPI:1770135915
Name:BUMGARDNER, SHAWNA (COUNSELOR)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:BUMGARDNER
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MCCOY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4931
Mailing Address - Country:US
Mailing Address - Phone:304-544-4303
Mailing Address - Fax:
Practice Address - Street 1:2001 MCCOY RD STE 105
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-4931
Practice Address - Country:US
Practice Address - Phone:304-544-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0357956Medicaid