MEDICARE: SHELLY FAIN CLUBB LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0011281	CO

General Provider Information

NPI Number	:	1356687636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY FAIN CLUBB LPC

Provider Business Mailing Address
First Line	:	2352 MEADOWS BLVD STE 300
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80109-8419
Country	:	US
Telephone Number	:	720-455-3750
Fax Number	:	720-455-3751

Provider Business Practice Location Address
First Line	:	4611 PLETTNER LN
Second Line	:	SUITE 104
City	:	EVERGREEN
State	:	CO
Zip	:	80439-7396
Country	:	US
Telephone Number	:	720-448-6925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2012
Last Update Date	:	03/17/2018

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