Provider Demographics
NPI:1871642371
Name:KEGLAR, SHELVY HAYWOOD (PHD)
Entity type:Individual
Prefix:
First Name:SHELVY
Middle Name:HAYWOOD
Last Name:KEGLAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2744
Mailing Address - Country:US
Mailing Address - Phone:317-923-3930
Mailing Address - Fax:317-923-2441
Practice Address - Street 1:525 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2744
Practice Address - Country:US
Practice Address - Phone:317-923-3930
Practice Address - Fax:317-923-2441
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040520A103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100235970AMedicaid
IN000000183364OtherANTHEM
IN273950AMedicare ID - Type Unspecified