Provider Demographics
NPI:1013563162
Name:SHACKLETON, TABITHA KAY
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:KAY
Last Name:SHACKLETON
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 1:6632 W MISSISSIPPI WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-5668
Mailing Address - Country:US
Mailing Address - Phone:720-297-0295
Mailing Address - Fax:
Practice Address - Street 1:6632 W MISSISSIPPI WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-5668
Practice Address - Country:US
Practice Address - Phone:720-297-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker