Provider Demographics
NPI:1073828414
Name:SHACKLEFORD, WENDY KIM (EDD, LPCC, NCC)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:KIM
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:EDD, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 GRANVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1076
Mailing Address - Country:US
Mailing Address - Phone:740-687-0833
Mailing Address - Fax:
Practice Address - Street 1:1592 GRANVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1076
Practice Address - Country:US
Practice Address - Phone:740-687-0833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH270475101YM0800X
OHE1000054101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health