Basic Information
| Provider Information | |||||||||
| NPI: | 1003869116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 WASHINGTON AVE # 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140550 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3900 WASHINGTON AVE # 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477140550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124856694 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 6301012872 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | 1799 | AL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | P108974770 | 01 | MI | BCBS PERSONAL PIN | OTHER |