Provider Demographics
NPI:1861504995
Name:TULLY, SHAWNA (LMFT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 E US HIGHWAY 36 STE 100
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6646
Mailing Address - Country:US
Mailing Address - Phone:888-714-1927
Mailing Address - Fax:317-745-9565
Practice Address - Street 1:1600 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2388
Practice Address - Country:US
Practice Address - Phone:317-574-1254
Practice Address - Fax:317-674-0060
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001421A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist