Provider Demographics
NPI:1821244658
Name:SHAKOCIUS, NISSA BLAIR (LCSW)
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:BLAIR
Last Name:SHAKOCIUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PLEASANT VALLEY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5683
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:830-214-2576
Practice Address - Street 1:113 PLEASANT VALLEY DR STE 210
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-5683
Practice Address - Country:US
Practice Address - Phone:830-267-4575
Practice Address - Fax:830-214-2576
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287224402Medicaid
TX2872244-08Medicaid