Provider Demographics
NPI:1316361801
Name:SHACKLEFORD, PATRICA (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICA
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 SE COUNTY ROAD 21B
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-5113
Mailing Address - Country:US
Mailing Address - Phone:352-475-3311
Mailing Address - Fax:866-811-2779
Practice Address - Street 1:2380 SE COUNTY ROAD 21B
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-5113
Practice Address - Country:US
Practice Address - Phone:352-475-3311
Practice Address - Fax:866-811-2779
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5805101YM0800X
FLSS 475103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool