Provider Demographics
NPI:1952931594
Name:SWOVERLAND, SHANE MILES (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MILES
Last Name:SWOVERLAND
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 1:2500 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4728
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:260-460-1481
Practice Address - Street 1:2500 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4728
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-460-1481
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008679A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical