Provider Demographics
NPI:1861600207
Name:DRISCOLL, SHELLEY A (MA)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:A
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13664-0027
Mailing Address - Country:US
Mailing Address - Phone:315-375-4249
Mailing Address - Fax:
Practice Address - Street 1:505 E COMMONWEALTH AVE
Practice Address - Street 2:STE. 200
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2020
Practice Address - Country:US
Practice Address - Phone:714-879-9616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 30288106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist