Provider Demographics
NPI:1528479755
Name:KELLY, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 GARDEN CIR
Mailing Address - Street 2:UNIT C
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8557
Mailing Address - Country:US
Mailing Address - Phone:530-903-0662
Mailing Address - Fax:
Practice Address - Street 1:3061 GARDEN CIR
Practice Address - Street 2:UNIT C
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8557
Practice Address - Country:US
Practice Address - Phone:530-903-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health