Provider Demographics
NPI:1083759971
Name:SOMMERFELDT, SHELLEY K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:K
Last Name:SOMMERFELDT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 LAGARTO RD
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7437
Mailing Address - Country:US
Mailing Address - Phone:213-446-4266
Mailing Address - Fax:
Practice Address - Street 1:8 LAGARTO RD
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7437
Practice Address - Country:US
Practice Address - Phone:213-446-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22294103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEZ226ZMedicare PIN