Basic Information
| Provider Information | |||||||||
| NPI: | 1770694291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLY | ||||||||
| FirstName: | SANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Practice Location | |||||||||
| Address1: | 498 NW 18TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473742851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653738704 | ||||||||
| FaxNumber: | 7654882609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/12/2018 | ||||||||
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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 | 1041C0700X | 34001154A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.