Provider Demographics
NPI:1083785182
Name:SHAKES, MARY JUANITA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JUANITA
Last Name:SHAKES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1127
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732
Mailing Address - Country:US
Mailing Address - Phone:334-341-7400
Mailing Address - Fax:334-287-2331
Practice Address - Street 1:205 HERBERT STREET
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-341-7400
Practice Address - Fax:601-485-5215
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0113C1041C0700X
MSC72641041C0700X
MS0113C1041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00408326OtherMEDICARE RAILROAD
800000340Medicare PIN
800000340Medicare UPIN