Basic Information
| Provider Information | |||||||||
| NPI: | 1750324489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SYSUM | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUPP | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176769788 | ||||||||
| FaxNumber: | 5176763438 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EATON RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488271426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176678447 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301010330 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.