Provider Demographics
NPI:1669943395
Name:SHIRLEY, SHIRLENE KELLY (SUDP)
Entity type:Individual
Prefix:MS
First Name:SHIRLENE
Middle Name:KELLY
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12715 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1027
Mailing Address - Country:US
Mailing Address - Phone:509-323-5766
Mailing Address - Fax:509-321-5472
Practice Address - Street 1:3710 N MONROE ST. RIVERSIDE RECOVERY CENTER
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205
Practice Address - Country:US
Practice Address - Phone:509-328-5234
Practice Address - Fax:509-328-2358
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60081248101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid
WA2118932Medicaid