Provider Demographics
NPI:1891338307
Name:SHACKET, KEVIN B (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:B
Last Name:SHACKET
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 CONNELL DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4234
Mailing Address - Country:US
Mailing Address - Phone:321-303-9593
Mailing Address - Fax:
Practice Address - Street 1:781 CONNELL DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-4234
Practice Address - Country:US
Practice Address - Phone:321-303-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10532103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical