Provider Demographics
NPI:1568867786
Name:SHACKELFORD, ROBERT (ASW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 ALTA SIERRA AVE # A
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9629
Mailing Address - Country:US
Mailing Address - Phone:951-256-6174
Mailing Address - Fax:
Practice Address - Street 1:2731 NUGGET AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9456
Practice Address - Country:US
Practice Address - Phone:760-379-3412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW927981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health