Basic Information
| Provider Information | |||||||||
| NPI: | 1619509189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIRLEY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LOGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636192809 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636192809 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | RBT-20-112091 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.