Provider Demographics
NPI:1154430395
Name:SHORLEY, MARLIN DALE (LPC, MA)
Entity type:Individual
Prefix:MR
First Name:MARLIN
Middle Name:DALE
Last Name:SHORLEY
Suffix:
Gender:M
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 MAIN ST
Mailing Address - Street 2:STE. 401
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-2646
Mailing Address - Country:US
Mailing Address - Phone:816-753-7071
Mailing Address - Fax:816-753-8189
Practice Address - Street 1:4901 MAIN ST
Practice Address - Street 2:STE. 401
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64112-2646
Practice Address - Country:US
Practice Address - Phone:816-753-7071
Practice Address - Fax:816-753-8189
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000615101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20754063OtherBC/BS OF KC
KS567219OtherBC/BS KS
52709OtherCIGNA
0007091Medicare ID - Type Unspecified