=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770657017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES S SHINAVER III PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 04/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6911 ANTIQUITY DR
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46033-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-641-7794
-----------------------------------------------------
Fax | 317-641-7794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6911 ANTIQUITY DR
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46033-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-641-7794
-----------------------------------------------------
Fax | 317-641-7794
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20041158A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------