Healthcare Provider Details

I. General information

NPI: 1902497522
Provider Name (Legal Business Name): SHANNON AARDEMA M.ED., ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 RANSOM RD
VALPARAISO IN
46385-8973
US

IV. Provider business mailing address

750 RANSOM RD
VALPARAISO IN
46385-8973
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-9607
  • Fax: 219-548-8064
Mailing address:
  • Phone: 219-464-9607
  • Fax: 219-548-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1600334
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: