Healthcare Provider Details

I. General information

NPI: 1063457190
Provider Name (Legal Business Name): RONALD L SHOEMAKER LSCW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OAKLAND AVE
ELKHART IN
46517-1533
US

IV. Provider business mailing address

330 LAKEVIEW DR
GOSHEN IN
46528-9365
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-1234
  • Fax: 574-537-2652
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001890
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: