Provider Demographics
NPI:1134405533
Name:SHACKFORD, SHANE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:SHACKFORD
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 1:325 E JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 182
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4126
Mailing Address - Country:US
Mailing Address - Phone:609-325-8775
Mailing Address - Fax:
Practice Address - Street 1:325 E JIMMIE LEEDS RD
Practice Address - Street 2:SUITE 182
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-4126
Practice Address - Country:US
Practice Address - Phone:609-325-8775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2516103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool