Provider Demographics
NPI:1457451924
Name:SHACKELFORD, RONALD CONWAY (DMIN, MS, MFT)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CONWAY
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:DMIN, MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23381 SAINT ANDREWS
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692
Mailing Address - Country:US
Mailing Address - Phone:949-455-1017
Mailing Address - Fax:949-472-4403
Practice Address - Street 1:23381 SAINT ANDREWS
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692
Practice Address - Country:US
Practice Address - Phone:949-455-1017
Practice Address - Fax:949-472-4403
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT #36608106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist