Provider Demographics
NPI:1275583296
Name:SHINEDLING, MARTIN M (PHD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:M
Last Name:SHINEDLING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 E CENTER ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-6456
Mailing Address - Country:US
Mailing Address - Phone:435-652-3775
Mailing Address - Fax:435-652-8334
Practice Address - Street 1:272 E CENTER ST
Practice Address - Street 2:SUITE 207
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738-6456
Practice Address - Country:US
Practice Address - Phone:435-652-3775
Practice Address - Fax:435-652-8334
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6906880-2501103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680Z910100OtherBLUE CROSS
MIP25143FOtherBLUE CARE NETWORK
MI680Z910100OtherBLUE CROSS