Provider Demographics
NPI:1962266973
Name:BALES, SHAMIRON (PHD)
Entity type:Individual
Prefix:DR
First Name:SHAMIRON
Middle Name:
Last Name:BALES
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3252 HOLIDAY CT STE 114
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-0027
Mailing Address - Country:US
Mailing Address - Phone:619-380-0508
Mailing Address - Fax:
Practice Address - Street 1:3252 HOLIDAY CT STE 114
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0027
Practice Address - Country:US
Practice Address - Phone:619-380-0508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34832103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist