Provider Demographics
NPI:1205831104
Name:SHESTAK, CHRISTINE OTTAVIANO (MS LMHC)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:OTTAVIANO
Last Name:SHESTAK
Suffix:
Gender:F
Credentials:MS LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-0205
Mailing Address - Country:US
Mailing Address - Phone:260-824-0089
Mailing Address - Fax:260-824-4209
Practice Address - Street 1:109 N SCOTT ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-2004
Practice Address - Country:US
Practice Address - Phone:260-824-0089
Practice Address - Fax:260-824-4209
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000248A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN345600OtherMANAGED HEALTH NETWORK
IN473559000OtherMAGELLAN
IN000000324156OtherANTHEM BLUE CROSS
IN200456370AMedicaid
IN512125OtherVALUEOPTIONS