Basic Information
| Provider Information | |||||||||
| NPI: | 1407480577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEHANE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
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| Credential: | PEER SUPPORTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 KENMORE AVE NE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444834232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307709657 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5760 PATRIOT BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTINTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445151170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309530243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2020 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 175T00000X | OH | Y |
No ID Information.