Provider Demographics
NPI:1528363561
Name:SHAFFER, REBECCA (PSYD)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML - 4002
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-9645
Mailing Address - Fax:513-636-3800
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML - 4002
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-9645
Practice Address - Fax:513-636-3800
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IN20042577A103TC0700X
OH7014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201086690Medicaid
IN000000785009OtherANTHEM
IN000000785009OtherANTHEM