Provider Demographics
NPI:1205976099
Name:SUSAN L SHACKELFORD, PHD & ASSOCIATES, PA
Entity type:Organization
Organization Name:SUSAN L SHACKELFORD, PHD & ASSOCIATES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-443-5575
Mailing Address - Street 1:1 W SUNBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1825
Mailing Address - Country:US
Mailing Address - Phone:479-443-5575
Mailing Address - Fax:479-443-9554
Practice Address - Street 1:1 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1825
Practice Address - Country:US
Practice Address - Phone:479-443-5575
Practice Address - Fax:479-443-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR97-04P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T520OtherBLUECROSS BLUESHIELD