Provider Demographics
NPI:1558315820
Name:SHATTUCK, DANIEL WATKINS (PHD, LCMHC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WATKINS
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:PHD, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 ATRIUM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6452
Mailing Address - Country:US
Mailing Address - Phone:919-763-2760
Mailing Address - Fax:919-359-9705
Practice Address - Street 1:2501 ATRIUM DR STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6452
Practice Address - Country:US
Practice Address - Phone:919-763-2760
Practice Address - Fax:919-359-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3398101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102454Medicaid
NCE0478OtherMEDCOST PREFERRED
NC75888OtherBLUE CROSS AND BLUE SHIEL