Basic Information
| Provider Information | |||||||||
| NPI: | 1447874748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARKAS | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 547 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432112603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142244506 | ||||||||
| FaxNumber: | 6142910118 | ||||||||
| Practice Location | |||||||||
| Address1: | 547 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432112603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142244506 | ||||||||
| FaxNumber: | 6142910118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2020 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.140584 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0406357 | 05 | OH | MEDICAID |