Healthcare Provider Details

I. General information

NPI: 1396562070
Provider Name (Legal Business Name): KASSANDRA A. R. SHELLABARGER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 WISHARD BLVD
INDIANAPOLIS IN
46202-2872
US

IV. Provider business mailing address

PO BOX 719094
CHICAGO IL
60677-9318
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-4779
  • Fax: 317-948-9806
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20044050B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20044050B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: