Provider Demographics
NPI:1013568666
Name:SHIRES, ELYSE L (RBT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:L
Last Name:SHIRES
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9197 W 6TH AVE STE 1000
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-5109
Mailing Address - Country:US
Mailing Address - Phone:303-233-3122
Mailing Address - Fax:
Practice Address - Street 1:9197 W 6TH AVE STE 1000
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-5109
Practice Address - Country:US
Practice Address - Phone:303-233-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-96620106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORBT-19-96620OtherMEDICAID AND KAISER