Provider Demographics
NPI:1326399387
Name:SHACKELFORD, TERESA I (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:I
Last Name:SHACKELFORD
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 1:6263 W COHIBA LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2848
Mailing Address - Country:US
Mailing Address - Phone:208-284-0377
Mailing Address - Fax:
Practice Address - Street 1:7275 W POTOMAC DR
Practice Address - Street 2:STE. A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9150
Practice Address - Country:US
Practice Address - Phone:208-284-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-313751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical