Provider Demographics
NPI:1568998086
Name:SLACK, SHEENA (LMSW, LMAC, CRAADC)
Entity Type:Individual
Prefix:
First Name:SHEENA
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:LMSW, LMAC, CRAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WESTWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3519
Mailing Address - Country:US
Mailing Address - Phone:816-781-8550
Mailing Address - Fax:
Practice Address - Street 1:30 WESTWOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3519
Practice Address - Country:US
Practice Address - Phone:816-781-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8043101YA0400X
KS100101YA0400X
KS10216104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker