Provider Demographics
NPI:1700361938
Name:SHACKLEFORD, KAYLEE
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:SHACKLEFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 JENKINS LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-9781
Mailing Address - Country:US
Mailing Address - Phone:615-519-7076
Mailing Address - Fax:
Practice Address - Street 1:2042 NASHVILLE PIKE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3161
Practice Address - Country:US
Practice Address - Phone:615-590-7213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health