Provider Demographics
NPI:1174063762
Name:OMLIN, SHIRLEY THEODORA (00501011536)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:THEODORA
Last Name:OMLIN
Suffix:
Gender:F
Credentials:00501011536
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:THEODORA
Other - Last Name:PRESLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-4007
Mailing Address - Country:US
Mailing Address - Phone:714-542-3581
Mailing Address - Fax:714-542-2246
Practice Address - Street 1:2101 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4007
Practice Address - Country:US
Practice Address - Phone:714-542-3581
Practice Address - Fax:714-542-2246
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00501011536101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215030861OtherMEDICAL