Healthcare Provider Details

I. General information

NPI: 1164368015
Provider Name (Legal Business Name): STEPHEN SHOUP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BRENNA BINGAMAN

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 E COLLEGE AVE STE 1090
STATE COLLEGE PA
16801-7569
US

IV. Provider business mailing address

3500 E COLLEGE AVE STE 1090
STATE COLLEGE PA
16801-7569
US

V. Phone/Fax

Practice location:
  • Phone: 814-738-7655
  • Fax:
Mailing address:
  • Phone: 814-738-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number91813601
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: