Provider Demographics
NPI:1295820363
Name:SHOOK, NANCY J (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:SHOOK
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 BLACK FOREST LN
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE BRA
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5249
Mailing Address - Country:US
Mailing Address - Phone:765-446-1251
Mailing Address - Fax:
Practice Address - Street 1:500 W NAVAJO ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-1999
Practice Address - Country:US
Practice Address - Phone:765-464-1510
Practice Address - Fax:765-464-8361
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041541A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN070930OMedicare ID - Type Unspecified