Provider Demographics
NPI:1942367313
Name:ANDERSON CLARKE, SHAKESHA S
Entity Type:Individual
Prefix:
First Name:SHAKESHA
Middle Name:S
Last Name:ANDERSON CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5216 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-8759
Mailing Address - Country:US
Mailing Address - Phone:325-654-3122
Mailing Address - Fax:325-654-5161
Practice Address - Street 1:271 FT RICHARDSON AVE
Practice Address - Street 2:LIFE SKILLS SUPPORT CENTER- 17MDG
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-3122
Practice Address - Fax:325-654-5161
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist