Basic Information
Provider Information | |||||||||
NPI: | 1528007192 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHOOK | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 N FRENCH ST | ||||||||
Address2: |   | ||||||||
City: | SULLIVAN | ||||||||
State: | IN | ||||||||
PostalCode: | 478821424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122684805 | ||||||||
FaxNumber: | 8122422210 | ||||||||
Practice Location | |||||||||
Address1: | 701 N. ENGLEWOOD DRIVE | ||||||||
Address2: |   | ||||||||
City: | CRAWFORDSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 47933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7653619767 | ||||||||
FaxNumber: | 7653610374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 07/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34003254A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 000000343921 | 01 | IN | ANTHEM BCBS PROVIDER PIN | OTHER |