Provider Demographics
NPI:1083108799
Name:SHIVELY, JAMES L II (CDCA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:SHIVELY
Suffix:II
Gender:M
Credentials:CDCA
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 1212
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44482-1212
Mailing Address - Country:US
Mailing Address - Phone:330-469-6822
Mailing Address - Fax:330-294-5641
Practice Address - Street 1:1212 TOD PL NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2475
Practice Address - Country:US
Practice Address - Phone:330-469-6822
Practice Address - Fax:330-294-5641
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)