Provider Demographics
NPI:1477040210
Name:PEARSON, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PEARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1716
Mailing Address - Country:US
Mailing Address - Phone:765-680-0071
Mailing Address - Fax:
Practice Address - Street 1:1122 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1759
Practice Address - Country:US
Practice Address - Phone:765-680-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003118A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health