Provider Demographics
NPI:1043713688
Name:SHANE, RACHEL (LCSW)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:SHANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13700 WOOD FLOWER CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4703
Mailing Address - Country:US
Mailing Address - Phone:269-325-9652
Mailing Address - Fax:
Practice Address - Street 1:53846 GENERATIONS DR STE A
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1543
Practice Address - Country:US
Practice Address - Phone:574-366-2854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007759A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor