Provider Demographics
NPI:1194217612
Name:SHACKLETTE, MICHAEL DAVID (LPCC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SHACKLETTE
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUWANNEE TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7956
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:512 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164-8443
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100878810Medicaid