Provider Demographics
NPI:1942854054
Name:MILGROM, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:MILGROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5248 CLAREMONT AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1057
Mailing Address - Country:US
Mailing Address - Phone:559-970-7117
Mailing Address - Fax:
Practice Address - Street 1:1266 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2247
Practice Address - Country:US
Practice Address - Phone:510-616-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X, 390200000X, 101YM0800X
CA17807101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251K00000XAgenciesPublic Health or Welfare
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program