Provider Demographics
NPI:1689435711
Name:PASSMORE, SHANESE (LMFTA)
Entity Type:Individual
Prefix:
First Name:SHANESE
Middle Name:
Last Name:PASSMORE
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 CANDLETREE CIR APT 5
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2802
Mailing Address - Country:US
Mailing Address - Phone:219-628-2779
Mailing Address - Fax:
Practice Address - Street 1:5110 COMMERCE SQUARE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8554
Practice Address - Country:US
Practice Address - Phone:317-412-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000497A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist