Provider Demographics
NPI:1720967474
Name:SHOEMAKER, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHOEMAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S MAIN ST STE 305
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-2361
Mailing Address - Country:US
Mailing Address - Phone:567-429-1000
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN ST STE 305
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-2361
Practice Address - Country:US
Practice Address - Phone:567-429-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2204630101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional