Provider Demographics
NPI:1750645792
Name:SHURIG, EDWIN L (MAMFT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:L
Last Name:SHURIG
Suffix:
Gender:M
Credentials:MAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3166 E BRAESIDE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-4391
Mailing Address - Country:US
Mailing Address - Phone:812-360-5737
Mailing Address - Fax:
Practice Address - Street 1:3166 E BRAESIDE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-4391
Practice Address - Country:US
Practice Address - Phone:812-360-5737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002310A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health