Provider Demographics
NPI:1902847759
Name:SHACKELFORD, LOANNE M (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:LOANNE
Middle Name:M
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:LA VETA
Mailing Address - State:CO
Mailing Address - Zip Code:81055-0148
Mailing Address - Country:US
Mailing Address - Phone:719-742-3372
Mailing Address - Fax:719-742-3373
Practice Address - Street 1:200 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:LA VETA
Practice Address - State:CO
Practice Address - Zip Code:81055-0148
Practice Address - Country:US
Practice Address - Phone:719-742-3372
Practice Address - Fax:719-742-3373
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9910751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO035334Medicaid
CO035334Medicaid
COP30174Medicare UPIN