Provider Demographics
NPI:1144213711
Name:SHEAR, MARY LOCKE (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOCKE
Last Name:SHEAR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:7337 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6284
Mailing Address - Country:US
Mailing Address - Phone:260-436-7131
Mailing Address - Fax:260-436-5123
Practice Address - Street 1:7337 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6284
Practice Address - Country:US
Practice Address - Phone:260-436-7131
Practice Address - Fax:260-436-5123
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040180103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100090960Medicaid
IN220850Medicare ID - Type Unspecified