Provider Demographics
NPI:1851088512
Name:SHAFFER, NICHOLAS J
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
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 1:5 SUGAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-9612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 SUGAR CREEK RD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-9612
Practice Address - Country:US
Practice Address - Phone:573-223-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician