Provider Demographics
NPI:1750324489
Name:SYSUM, SHELLEY RAE (PSYD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:RAE
Last Name:SYSUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:RAE
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:517-676-3438
Practice Address - Street 1:600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1426
Practice Address - Country:US
Practice Address - Phone:517-667-8447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist