Provider Demographics
NPI:1386712354
Name:SHANE, RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:SHANE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 BROADWAY ST
Mailing Address - Street 2:SUITE 103-165
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1133
Mailing Address - Country:US
Mailing Address - Phone:303-304-9933
Mailing Address - Fax:720-294-8350
Practice Address - Street 1:3980 BROADWAY ST
Practice Address - Street 2:SUITE 103-165
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1133
Practice Address - Country:US
Practice Address - Phone:303-304-9933
Practice Address - Fax:720-294-8350
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health