Provider Demographics
NPI:1780299461
Name:LIAROS, SHELLY (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:LIAROS
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 DARE RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2716
Mailing Address - Country:US
Mailing Address - Phone:757-597-4818
Mailing Address - Fax:
Practice Address - Street 1:405 GRAFTON DR
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2155
Practice Address - Country:US
Practice Address - Phone:757-597-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0803000173103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool