Provider Demographics
NPI:1831501113
Name:SHEPLEY, BERT
Entity type:Individual
Prefix:
First Name:BERT
Middle Name:
Last Name:SHEPLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BAYSIDE DRIVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625
Mailing Address - Country:US
Mailing Address - Phone:714-642-3991
Mailing Address - Fax:
Practice Address - Street 1:1111 BAYSIDE DRIVE
Practice Address - Street 2:SUITE 212
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:714-642-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC87943106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist