Provider Demographics
NPI:1568851095
Name:ANDREA SHELLEY, CLINICAL & FORENSIC PSYCHOLOGY, A PROFESSIONAL CORPORA
Entity Type:Organization
Organization Name:ANDREA SHELLEY, CLINICAL & FORENSIC PSYCHOLOGY, A PROFESSIONAL CORPORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:415-515-3211
Mailing Address - Street 1:1832 CENTRO WEST ST
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-1909
Mailing Address - Country:US
Mailing Address - Phone:415-515-3211
Mailing Address - Fax:
Practice Address - Street 1:1832 CENTRO WEST ST
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-1909
Practice Address - Country:US
Practice Address - Phone:415-515-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHD866AOtherMEDICARE PART B
CA113038OtherMEDICARE PART B