Provider Demographics
NPI:1063503498
Name:WILLARD, SHIRLEY BAILEY (MA)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:BAILEY
Last Name:WILLARD
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 1:204 PENN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHUMBERLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17857-8406
Mailing Address - Country:US
Mailing Address - Phone:570-473-7516
Mailing Address - Fax:
Practice Address - Street 1:204 PENN ST
Practice Address - Street 2:
Practice Address - City:NORTHUMBERLAND
Practice Address - State:PA
Practice Address - Zip Code:17857-8406
Practice Address - Country:US
Practice Address - Phone:570-473-7516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007734L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist