Active NPI
Shirley Grace Roark, PH.D.
- Clinical Psychologist
- Indio, CA
National Provider Identifier
1417003104
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY17934
- Practice address
- 83203 Indio Blvd
Suite 2
Indio, CA 92201-4700 - Phone
- (760) 342-1420
- Fax
- (760) 342-1429
- NPI assigned
- Jan 26, 2007
- Last updated
- Jul 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY17934 | CA | Primary |
Addresses
Primary practice location
83203 Indio Blvd
Suite 2
Indio, CA 92201-4700
Mailing address
3250 Wilshire Blvd
Suite 930
Los Angeles, CA 90010-1438
Phone (213) 739-0019
Other names 1
- Dr. Shirley Grace Roark
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY17934 | CA | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Champion Medical Group | Clinical | Past | Accepting new patients |
| Socal Psychiatric Medical Group, a Medical Corporation | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Universal Psychiatric Center
- Clinical Psychologist
- Los Angeles, CA
- NPI 1619151305
-
dba Industrial Psychiatric Network
- Psychologist
- Los Angeles, CA
- NPI 1770686347
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1169769600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1417003104",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3250 WILSHIRE BLVD",
"address_2": "SUITE 930",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900101438",
"telephone_number": "213-739-0019",
"fax_number": "213-739-0091"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "83203 INDIO BLVD",
"address_2": "SUITE 2",
"city": "INDIO",
"state": "CA",
"postal_code": "922014700",
"telephone_number": "760-342-1420",
"fax_number": "760-342-1429"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROARK",
"first_name": "SHIRLEY",
"middle_name": "GRACE",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-01-26",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY17934",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "SHIRLEY",
"last_name": "ROARK",
"middle_name": "GRACE",
"prefix": "DR.",
"credential": "PH.D.",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Indio, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.