Provider Demographics
NPI:1801264932
Name:STALEY, SHELLY ROSE VONK (LMFT 114352)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:ROSE VONK
Last Name:STALEY
Suffix:
Gender:F
Credentials:LMFT 114352
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:ROSE
Other - Last Name:VONK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PMB 277
Mailing Address - Street 2:3940-7 BROAD STREET
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-215-3738
Mailing Address - Fax:
Practice Address - Street 1:PMB 277
Practice Address - Street 2:3940-7 BROAD STREET
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-215-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-06
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT114352106H00000X, 106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program