MEDICARE: MICHELLE E MASTIN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	6301012872	MI
2	103TC2200X	Clinical Child & Adolescent Psychologist	1799	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P108974770	OTHER	MI	BCBS PERSONAL PIN

General Provider Information

NPI Number	:	1003869116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE E MASTIN PHD

Provider Business Mailing Address
First Line	:	3900 WASHINGTON AVE # 100
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-0550
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 WASHINGTON AVE # 100
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-0550
Country	:	US
Telephone Number	:	812-485-6694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	08/29/2024

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Directions to “ MICHELLE E MASTIN PHD” Practice Location

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