Healthcare Provider Details

I. General information

NPI: 1265471197
Provider Name (Legal Business Name): RUTH MARIE SHALLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MEDIC WAY
GREENCASTLE IN
46135-2296
US

IV. Provider business mailing address

156 ANDREWS BLVD
PLAINFIELD IN
46168-9769
US

V. Phone/Fax

Practice location:
  • Phone: 765-653-2669
  • Fax: 765-653-8671
Mailing address:
  • Phone: 317-371-2302
  • Fax: 765-653-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34004443A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: