Basic Information
| Provider Information | |||||||||
| NPI: | 1275683013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTUM | ||||||||
| FirstName: | SHARYL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 BIELBY RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470251055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125371302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 427 W EADS PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470251139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125377375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20041835A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000255683 | 01 | IN | BLUE SHIELD | OTHER |