Healthcare Provider Details

I. General information

NPI: 1457431264
Provider Name (Legal Business Name): SHIRLEY JOAN SMART PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHIRLEY JOANN SMART PHD

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 INTELLIPLEX DR STE 207
SHELBYVILLE IN
46176-8546
US

IV. Provider business mailing address

30 W RAMPART ST STE 200
SHELBYVILLE IN
46176-8846
US

V. Phone/Fax

Practice location:
  • Phone: 317-392-2971
  • Fax:
Mailing address:
  • Phone: 317-421-2012
  • Fax: 317-398-1851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3805
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043442A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: