Provider Demographics
NPI:1063878130
Name:KELLEY, SHAYNE THOMAS
Entity type:Individual
Prefix:MR
First Name:SHAYNE
Middle Name:THOMAS
Last Name:KELLEY
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 1:187 E WILBUR RD STE 14
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7938
Mailing Address - Country:US
Mailing Address - Phone:818-253-4150
Mailing Address - Fax:
Practice Address - Street 1:187 E WILBUR RD STE 14
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7938
Practice Address - Country:US
Practice Address - Phone:818-253-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)