Provider Demographics
NPI:1598955429
Name:SHANKS, ALISA LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALISA
Middle Name:LYNN
Last Name:SHANKS
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 7043
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-0018
Mailing Address - Country:US
Mailing Address - Phone:303-492-2038
Mailing Address - Fax:
Practice Address - Street 1:WARDENBURG STUDENT HEALTH CENTER - PHP
Practice Address - Street 2:UCB 119
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-0001
Practice Address - Country:US
Practice Address - Phone:303-492-2038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical