Provider Demographics
NPI:1649588690
Name:SHAFFER, PHILIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-2425
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:
Practice Address - Street 1:180 MARTIN DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-2425
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6951103TC1900X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy