Provider Demographics
NPI:1770025678
Name:SHIRLEY, RONDA
Entity Type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 LONG RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1611
Mailing Address - Country:US
Mailing Address - Phone:478-951-8776
Mailing Address - Fax:
Practice Address - Street 1:239 SMITHVILLE CHURCH RD
Practice Address - Street 2:STE B
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6485
Practice Address - Country:US
Practice Address - Phone:478-951-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001503106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist