Provider Demographics
NPI:1265471197
Name:SHALLEY, RUTH MARIE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:RUTH
Middle Name:MARIE
Last Name:SHALLEY
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 1:156 ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-9769
Mailing Address - Country:US
Mailing Address - Phone:317-371-2302
Mailing Address - Fax:765-653-8671
Practice Address - Street 1:308 MEDIC WAY
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2296
Practice Address - Country:US
Practice Address - Phone:765-653-2669
Practice Address - Fax:765-653-8671
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004443A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000207865OtherANTHEM BCBS PROVIDER PIN
IN000000207865OtherANTHEM BCBS PROVIDER PIN