Healthcare Provider Details

I. General information

NPI: 1811228752
Provider Name (Legal Business Name): SHALENE MICHELE KIRKLEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N 6TH AVE
PHOENIX AZ
85003-1318
US

IV. Provider business mailing address

PO BOX 94401
PHOENIX AZ
85070-4401
US

V. Phone/Fax

Practice location:
  • Phone: 602-284-7741
  • Fax: 480-219-9685
Mailing address:
  • Phone: 602-284-7741
  • Fax: 480-219-9685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4075
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number4075
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number4075
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4075
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number4075
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: