Provider Demographics
NPI:1891977435
Name:MINOR, SHELLY DENISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:DENISE
Last Name:MINOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:DENISE
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:6327 BETHEL ISLAND ROAD SUITE A
Mailing Address - Street 2:
Mailing Address - City:BETHEL ISLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94511
Mailing Address - Country:US
Mailing Address - Phone:925-550-0540
Mailing Address - Fax:925-684-0348
Practice Address - Street 1:6327 BETHEL ISLAND ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BETHEL ISLAND
Practice Address - State:CA
Practice Address - Zip Code:94511-1011
Practice Address - Country:US
Practice Address - Phone:925-550-0540
Practice Address - Fax:925-684-0348
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist