Provider Demographics
NPI:1063493112
Name:SHRUM, REBECCA A (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:SHRUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844B MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5331
Mailing Address - Country:US
Mailing Address - Phone:781-863-8489
Mailing Address - Fax:
Practice Address - Street 1:1844B MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5331
Practice Address - Country:US
Practice Address - Phone:781-863-8489
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04875OtherBLUECROSS/BLUESHIELD MA
MAW04875OtherBLUECROSS/BLUESHIELD MA