MEDICARE: SHELLY STAAL MSW, ASW

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	1041C0700X	Clinical Social Worker	85126	CA

General Provider Information

NPI Number	:	1528832870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY STAAL MSW, ASW

Provider Business Mailing Address
First Line	:	1206 S O ST
Second Line	:
City	:	TULARE
State	:	CA
Zip	:	93274-6534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1206 S O ST
Second Line	:
City	:	TULARE
State	:	CA
Zip	:	93274-6534
Country	:	US
Telephone Number	:	559-687-1173
Fax Number	:

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

Provider Enumeration Date	:	11/08/2023
Last Update Date	:	11/08/2023

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