Basic Information
| Provider Information | |||||||||
| NPI: | 1245328111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | CONLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 267 WHITE OAK RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925305182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148347861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 267 WHITE OAK RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925305182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148347861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.