Provider Demographics
NPI:1558497305
Name:KIELY, SHAWN JAY (MFT)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:JAY
Last Name:KIELY
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 BLUE GUM AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-1052
Mailing Address - Country:US
Mailing Address - Phone:209-525-5401
Mailing Address - Fax:209-525-5498
Practice Address - Street 1:2215 BLUE GUM AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-1052
Practice Address - Country:US
Practice Address - Phone:209-525-5401
Practice Address - Fax:209-525-5498
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 35578106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist