Healthcare Provider Details

I. General information

NPI: 1750324489
Provider Name (Legal Business Name): SHELLEY RAE SYSUM PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLEY RAE RUPP

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST
EATON RAPIDS MI
48827-1426
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-667-8447
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010330
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: