Provider Demographics
NPI:1710517396
Name:SHAFFER, ERIC M
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:M
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7811 TOBIE LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3857
Mailing Address - Country:US
Mailing Address - Phone:850-666-3732
Mailing Address - Fax:
Practice Address - Street 1:420 VICTORY PARK DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2484
Practice Address - Country:US
Practice Address - Phone:850-666-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3169101YM0800X
FL206961041C0700X
NE21931041C0700X
FLISW14267104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE12796OtherNEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
NE7674OtherNEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES
FLISW14267OtherFLORIDA DEPARTMENT OF HEALTH