Provider Demographics
NPI:1043030794
Name:SHINNESS, PATRICIA HART
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:HART
Last Name:SHINNESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46036-1362
Mailing Address - Country:US
Mailing Address - Phone:765-552-7378
Mailing Address - Fax:765-552-2017
Practice Address - Street 1:1207 N 19TH ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-1362
Practice Address - Country:US
Practice Address - Phone:765-552-7378
Practice Address - Fax:765-552-2017
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1111966103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool