Provider Demographics
NPI:1710418314
Name:WORTHAM, SHIRLEY
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHIRLEY
Other - Middle Name:ANN
Other - Last Name:WORTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:281728
Mailing Address - Street 1:1203 SAINT LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-5067
Mailing Address - Country:US
Mailing Address - Phone:608-436-1727
Mailing Address - Fax:
Practice Address - Street 1:2240 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2648
Practice Address - Country:US
Practice Address - Phone:608-361-7200
Practice Address - Fax:608-361-7202
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI281728101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)