Provider Demographics
NPI:1255185799
Name:SHACKLEFORD, SHIYAN ADORE
Entity type:Individual
Prefix:
First Name:SHIYAN
Middle Name:ADORE
Last Name:SHACKLEFORD
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 1:40 DAVENPORT ST
Mailing Address - Street 2:APT 511A
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2423
Mailing Address - Country:US
Mailing Address - Phone:586-265-0618
Mailing Address - Fax:
Practice Address - Street 1:40 DAVENPORT ST
Practice Address - Street 2:APT 511A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2423
Practice Address - Country:US
Practice Address - Phone:586-265-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily