Provider Demographics
NPI:1316582448
Name:SHACKELFORD, AISIA
Entity Type:Individual
Prefix:
First Name:AISIA
Middle Name:
Last Name:SHACKELFORD
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 1:11 GLENWOOD BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2318
Mailing Address - Country:US
Mailing Address - Phone:518-567-9757
Mailing Address - Fax:
Practice Address - Street 1:905 COUNTY BUILDING
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12413
Practice Address - Country:US
Practice Address - Phone:518-622-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105677104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker