Provider Demographics
NPI:1366455305
Name:SHACKELFORD, LON (PHD)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5354
Mailing Address - Country:US
Mailing Address - Phone:434-971-9611
Mailing Address - Fax:
Practice Address - Street 1:1011 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5354
Practice Address - Country:US
Practice Address - Phone:434-296-9161
Practice Address - Fax:434-296-1150
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000773103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA083119OtherVERI/OPTIMA
VA007711387Medicaid
VA333845OtherANTHEM