Provider Demographics
NPI:1437642626
Name:RICE, SHANE MATTHEW
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MATTHEW
Last Name:RICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 N MADISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-2301
Mailing Address - Country:US
Mailing Address - Phone:317-496-6929
Mailing Address - Fax:
Practice Address - Street 1:390 N MADISON AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2301
Practice Address - Country:US
Practice Address - Phone:317-496-6929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004821A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical