Provider Demographics
NPI:1447919089
Name:SHIRLEY, MONIQUE TERESE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:TERESE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:TERESE
Other - Last Name:MADISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1201 N MULDOON RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-6104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N MULDOON RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-6104
Practice Address - Country:US
Practice Address - Phone:907-580-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64128104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker