Provider Demographics
NPI:1780882274
Name:SHACKELFORD, ANNIE CELLA (LCSW)
Entity type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:CELLA
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:CELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-4708
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076335-1282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital