Provider Demographics
NPI:1306003611
Name:MILLICO, SHIRLEY ANN
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:ANN
Last Name:MILLICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 CROSSROADS RD.
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 CROSSROADS RD.
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:831-724-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#