Provider Demographics
NPI:1265463210
Name:POULSEN, SHRUTI SINGH (PHD)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:SINGH
Last Name:POULSEN
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 1:1508 SUMMIT DR.
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2228
Mailing Address - Country:US
Mailing Address - Phone:765-463-2995
Mailing Address - Fax:
Practice Address - Street 1:2201 FERRY ST
Practice Address - Street 2:HEARTLAND CLINIC
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3047
Practice Address - Country:US
Practice Address - Phone:765-446-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001468A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist