Provider Demographics
NPI:1417003104
Name:ROARK, SHIRLEY GRACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:GRACE
Last Name:ROARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SHIRLEY
Other - Middle Name:GRACE
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:3250 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 930
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1438
Mailing Address - Country:US
Mailing Address - Phone:213-739-0019
Mailing Address - Fax:213-739-0091
Practice Address - Street 1:83203 INDIO BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4700
Practice Address - Country:US
Practice Address - Phone:760-342-1420
Practice Address - Fax:760-342-1429
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17934103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical