Provider Demographics
NPI:1164757654
Name:RACKMILL, SHANA HEATHER (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:HEATHER
Last Name:RACKMILL
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 1:181 W MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092-2619
Mailing Address - Country:US
Mailing Address - Phone:860-836-0891
Mailing Address - Fax:
Practice Address - Street 1:49 ROBINWOOD AVE
Practice Address - Street 2:ARBOUR HOSPITAL- SOCIAL WORK DEPARTMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-2156
Practice Address - Country:US
Practice Address - Phone:617-522-4400
Practice Address - Fax:617-390-1595
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2148621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1821068818Medicaid