Provider Demographics
NPI:1124359005
Name:HART, SHELLEY (PPS)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BOLTON WALK
Mailing Address - Street 2:APT #101
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-4183
Mailing Address - Country:US
Mailing Address - Phone:530-902-4205
Mailing Address - Fax:
Practice Address - Street 1:429 N SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1399
Practice Address - Country:US
Practice Address - Phone:805-884-1629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050208099103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool