Provider Demographics
NPI:1629698774
Name:SHIRK, MARY JEAN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:SHIRK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 S 51ST ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-3231
Mailing Address - Country:US
Mailing Address - Phone:609-389-1628
Mailing Address - Fax:
Practice Address - Street 1:2506 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4639
Practice Address - Country:US
Practice Address - Phone:215-845-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAPS019648103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program