Provider Demographics
NPI:1881440840
Name:AULT, SHAYNE
Entity type:Individual
Prefix:
First Name:SHAYNE
Middle Name:
Last Name:AULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 CLARY BLVD. DR. S
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143
Mailing Address - Country:US
Mailing Address - Phone:812-900-2975
Mailing Address - Fax:
Practice Address - Street 1:3441 CLARY BLVD SOUTH DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-5525
Practice Address - Country:US
Practice Address - Phone:812-900-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health