Provider Demographics
NPI:1164486601
Name:SHIRLEY, NANCY LEAH (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LEAH
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:MSW LCSW
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 657
Mailing Address - Street 2:209 S PERU STREET SUITE 210 AND 211
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034
Mailing Address - Country:US
Mailing Address - Phone:317-984-5939
Mailing Address - Fax:317-984-2465
Practice Address - Street 1:209 S PERU STREET
Practice Address - Street 2:SUITE 210 211
Practice Address - City:CICERO
Practice Address - State:IN
Practice Address - Zip Code:46034
Practice Address - Country:US
Practice Address - Phone:317-984-5939
Practice Address - Fax:317-984-2465
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003573A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090760Medicare ID - Type Unspecified