Provider Demographics
NPI:1114049681
Name:LAACK, SHELLY D
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:D
Last Name:LAACK
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 1:4322 LEGACY CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2506
Mailing Address - Country:US
Mailing Address - Phone:209-468-3288
Mailing Address - Fax:209-468-8640
Practice Address - Street 1:620 N AURORA ST STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2276
Practice Address - Country:US
Practice Address - Phone:209-468-3720
Practice Address - Fax:209-468-8640
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)