Provider Demographics
NPI:1740944727
Name:SHACKLEFORD, DESTINY SHEA
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:SHEA
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 1:107 TWIN HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2242
Mailing Address - Country:US
Mailing Address - Phone:615-810-8180
Mailing Address - Fax:
Practice Address - Street 1:3010 HAMILL RD
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3322
Practice Address - Country:US
Practice Address - Phone:615-810-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health