Healthcare Provider Details

I. General information

NPI: 1295820363
Provider Name (Legal Business Name): NANCY J SHOOK PH.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W NAVAJO ST
WEST LAFAYETTE BRA IN
47906-1999
US

IV. Provider business mailing address

4342 BLACK FOREST LN
WEST LAFAYETTE BRA IN
47906-5249
US

V. Phone/Fax

Practice location:
  • Phone: 765-464-1510
  • Fax: 765-464-8361
Mailing address:
  • Phone: 765-446-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041541A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: