Provider Demographics
NPI:1245675396
Name:SHANKLE, TABATHA M (LCSW)
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:M
Last Name:SHANKLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63834-1030
Mailing Address - Country:US
Mailing Address - Phone:573-683-1211
Mailing Address - Fax:866-312-4304
Practice Address - Street 1:505 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MO
Practice Address - Zip Code:63834-1030
Practice Address - Country:US
Practice Address - Phone:573-683-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120116021041C0700X
MO20140307361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical