Provider Demographics
NPI:1902497522
Name:AARDEMA, SHANNON (MED, EDS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:AARDEMA
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 RANSOM RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8973
Mailing Address - Country:US
Mailing Address - Phone:219-464-9607
Mailing Address - Fax:219-548-8064
Practice Address - Street 1:750 RANSOM RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-8973
Practice Address - Country:US
Practice Address - Phone:219-464-9607
Practice Address - Fax:219-548-8064
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1600334103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool