Provider Demographics
NPI:1942478706
Name:SHACK, JOHN RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:SHACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 WILDERNESS DRIVE
Mailing Address - Street 2:P. O. BOX 140
Mailing Address - City:DOUGLAS
Mailing Address - State:MI
Mailing Address - Zip Code:49406-0140
Mailing Address - Country:US
Mailing Address - Phone:269-857-8644
Mailing Address - Fax:269-857-8644
Practice Address - Street 1:713 WILDERNESS DR.
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MI
Practice Address - Zip Code:49406-0140
Practice Address - Country:US
Practice Address - Phone:269-857-8644
Practice Address - Fax:269-857-8644
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011374103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP23020Medicare PIN