Provider Demographics
NPI:1326681107
Name:SHACKLETON, JUDITH AMBER (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:AMBER
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:JUDY
Other - Middle Name:A
Other - Last Name:SHACKLETON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:8323 REGENCY WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3817
Mailing Address - Country:US
Mailing Address - Phone:502-548-1209
Mailing Address - Fax:
Practice Address - Street 1:100 ENVOY CIR UNIT 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1807
Practice Address - Country:US
Practice Address - Phone:502-896-5669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY134527225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist