Provider Demographics
NPI:1679822084
Name:PARK, SHAWNA B (LISW-S, LCDC III)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:B
Last Name:PARK
Suffix:
Gender:F
Credentials:LISW-S, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2327 GAVINLEY WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-7335
Mailing Address - Country:US
Mailing Address - Phone:216-299-1517
Mailing Address - Fax:
Practice Address - Street 1:2327 GAVINLEY WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-7335
Practice Address - Country:US
Practice Address - Phone:216-299-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10121101YA0400X
OHI.11015991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)