Provider Demographics
NPI:1467599340
Name:SHACKELFORD, JOHN FLOYD I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FLOYD
Last Name:SHACKELFORD
Suffix:I
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 GATEWAY BLVD STE 405
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3627
Mailing Address - Country:US
Mailing Address - Phone:972-979-1949
Mailing Address - Fax:972-644-5512
Practice Address - Street 1:1701 GATEWAY BLVD STE 405
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3627
Practice Address - Country:US
Practice Address - Phone:972-979-1949
Practice Address - Fax:972-644-5512
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX99AJMedicare ID - Type Unspecified