Provider Demographics
NPI:1184758880
Name:BAESLER, SHELLY
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BAESLER
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 1:924 PROCK ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2054
Mailing Address - Country:US
Mailing Address - Phone:909-620-9715
Mailing Address - Fax:
Practice Address - Street 1:924 PROCK ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2054
Practice Address - Country:US
Practice Address - Phone:909-620-9715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC013520OtherLADMH STAFF CODE
CAICAN670OtherDMH STAFF CODE