=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346631371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN SHIRKEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2015
-----------------------------------------------------
Last Update Date | 05/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W MAIN STREET
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80443-1096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-409-7566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1096
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80443-1096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-409-7566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 18705
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------