Provider Demographics
NPI:1568518348
Name:SHIVELY, MARK S (LSPE)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:LSPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-4152
Mailing Address - Country:US
Mailing Address - Phone:423-267-2134
Mailing Address - Fax:423-267-2146
Practice Address - Street 1:515 TREMONT ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-4152
Practice Address - Country:US
Practice Address - Phone:423-267-2134
Practice Address - Fax:423-267-2146
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE1594103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist