Provider Demographics
NPI:1366023228
Name:SHIRLEY, BRANDY (LCPC)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4637
Mailing Address - Country:US
Mailing Address - Phone:217-398-9066
Mailing Address - Fax:217-398-9077
Practice Address - Street 1:309 W CLARK ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4637
Practice Address - Country:US
Practice Address - Phone:217-398-9066
Practice Address - Fax:217-398-9077
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011488101YM0800X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health