Provider Demographics
NPI:1316563174
Name:WELSH, SHELLY LEE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:LEE
Last Name:WELSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:LEE
Other - Last Name:WELSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:414 MADERA ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-6326
Mailing Address - Country:US
Mailing Address - Phone:925-580-4392
Mailing Address - Fax:
Practice Address - Street 1:414 MADERA ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-6326
Practice Address - Country:US
Practice Address - Phone:925-580-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist