Provider Demographics
NPI:1124624580
Name:SHOLLEY, PETER N
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:N
Last Name:SHOLLEY
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 1:215 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1169
Mailing Address - Country:US
Mailing Address - Phone:415-722-2409
Mailing Address - Fax:
Practice Address - Street 1:405 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2317
Practice Address - Country:US
Practice Address - Phone:415-820-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health