Basic Information
| Provider Information | |||||||||
| NPI: | 1083181333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAISLEY | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | ERIN | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7971 S 100 W | ||||||||
| Address2: | |||||||||
| City: | FAIRMOUNT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469289713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656183222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33008968A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.