Provider Demographics
NPI:1710418314
Name:WORTHAM, SHIRLEY
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHIRLEY
Other - Middle Name:ANN
Other - Last Name:WORTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC, LPC
Mailing Address - Street 1:N3152 STATE ROAD 81
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-9397
Mailing Address - Country:US
Mailing Address - Phone:608-328-9393
Mailing Address - Fax:
Practice Address - Street 1:N3152 STATE ROAD 81
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-9397
Practice Address - Country:US
Practice Address - Phone:608-328-9393
Practice Address - Fax:608-328-9480
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI281728101YA0400X
WI2817-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)