Provider Demographics
NPI:1770749442
Name:SHAFFER, THOMAS RAUBY (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAUBY
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 931
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-0931
Mailing Address - Country:US
Mailing Address - Phone:605-695-0651
Mailing Address - Fax:605-692-1883
Practice Address - Street 1:1310 MAIN AVE S
Practice Address - Street 2:SUITE 9
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-3819
Practice Address - Country:US
Practice Address - Phone:605-692-6367
Practice Address - Fax:605-692-1883
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD472103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6552660Medicaid
S102729OtherMEDICARE PTAN/ID