Provider Demographics
NPI:1689703464
Name:SHELLEY, PAUL E (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:E
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1506 OSOLO RD
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4122
Practice Address - Country:US
Practice Address - Phone:574-523-3347
Practice Address - Fax:574-296-7560
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003756A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000520385OtherANTHEM BCBS #
IN000000520385OtherANTHEM BCBS #
IN145540QMedicare PIN
INM40191010Medicare PIN