Provider Demographics
NPI:1881628956
Name:SHIRES, MICHAEL R (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:SHIRES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 KUTZTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LAURELDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19605-2661
Mailing Address - Country:US
Mailing Address - Phone:610-929-1840
Mailing Address - Fax:610-929-3810
Practice Address - Street 1:3212 KUTZTOWN RD
Practice Address - Street 2:
Practice Address - City:LAURELDALE
Practice Address - State:PA
Practice Address - Zip Code:19605-2661
Practice Address - Country:US
Practice Address - Phone:610-929-1840
Practice Address - Fax:610-929-3810
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005201L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling