Provider Demographics
NPI:1700609344
Name:SHIRLEY, EDISA (PHD, LMHC)
Entity type:Individual
Prefix:
First Name:EDISA
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 CANDLEBARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5358
Mailing Address - Country:US
Mailing Address - Phone:904-294-7041
Mailing Address - Fax:
Practice Address - Street 1:538 CANDLEBARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5358
Practice Address - Country:US
Practice Address - Phone:904-294-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health