Provider Demographics
NPI:1467950477
Name:SHAMALOV, MICHAEL (HSPP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SHAMALOV
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55107
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-0107
Mailing Address - Country:US
Mailing Address - Phone:317-253-7387
Mailing Address - Fax:
Practice Address - Street 1:500 8TH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-4072
Practice Address - Country:US
Practice Address - Phone:812-231-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0100X
IN20043100A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical