Basic Information
Provider Information | |||||||||
NPI: | 1669943395 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIRLEY | ||||||||
FirstName: | SHIRLENE | ||||||||
MiddleName: | KELLY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | SUDP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12715 E MISSION AVE | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 992161027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093235766 | ||||||||
FaxNumber: | 5093215472 | ||||||||
Practice Location | |||||||||
Address1: | 3710 N MONROE ST. RIVERSIDE RECOVERY CENTER | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 99205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093285234 | ||||||||
FaxNumber: | 5093282358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2018 | ||||||||
LastUpdateDate: | 10/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60081248 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 2077844 | 05 | WA |   | MEDICAID | 2118932 | 05 | WA |   | MEDICAID |