Provider Demographics
NPI:1053694372
Name:KELLEY, SHANE ANNA (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ANNA
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 KIETZKE LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3027
Mailing Address - Country:US
Mailing Address - Phone:775-853-3797
Mailing Address - Fax:855-754-6250
Practice Address - Street 1:5421 KIETZKE LN
Practice Address - Street 2:SUITE 101
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3027
Practice Address - Country:US
Practice Address - Phone:775-853-3797
Practice Address - Fax:855-754-6250
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NV0990106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist