Provider Demographics
NPI:1457431264
Name:SMART, SHIRLEY JOAN (PHD)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JOAN
Last Name:SMART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:JOANN
Other - Last Name:SMART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:30 W RAMPART ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8846
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:317-398-1851
Practice Address - Street 1:2325 INTELLIPLEX DR STE 207
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8546
Practice Address - Country:US
Practice Address - Phone:317-392-2971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3805103TC1900X
IN20043442A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty