Provider Demographics
NPI:1750474383
Name:SHACKLETON, BRUCE WARNER (EDD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WARNER
Last Name:SHACKLETON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 5232
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778
Mailing Address - Country:US
Mailing Address - Phone:508-655-6322
Mailing Address - Fax:508-655-9793
Practice Address - Street 1:35 MAIN STREET #3
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778
Practice Address - Country:US
Practice Address - Phone:508-655-6322
Practice Address - Fax:508-655-9793
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2621103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02692Medicare ID - Type UnspecifiedPROVIDER NUMBER