Provider Demographics
NPI:1750880696
Name:TANENBAUM, SHELLEY (PSYD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7533
Mailing Address - Country:US
Mailing Address - Phone:303-586-1586
Mailing Address - Fax:
Practice Address - Street 1:3575 LARKSPUR DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7533
Practice Address - Country:US
Practice Address - Phone:303-586-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical