Provider Demographics
NPI:1467830539
Name:COLLIER, SHALEISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHALEISE
Middle Name:
Last Name:COLLIER
Suffix:
Gender:F
Credentials:PHD
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 946
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-5946
Mailing Address - Country:US
Mailing Address - Phone:949-413-5070
Mailing Address - Fax:
Practice Address - Street 1:901 DOVER DR STE 210
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5500
Practice Address - Country:US
Practice Address - Phone:949-413-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33519103G00000X, 103T00000X, 103TC2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program