Provider Demographics
NPI:1811319585
Name:SHOCKLEY, KRISTA (M ED, LPC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14323 S OUTER 40 RD STE 512S
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5734
Mailing Address - Country:US
Mailing Address - Phone:314-526-0575
Mailing Address - Fax:
Practice Address - Street 1:14323 S OUTER 40 RD STE 512S
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5734
Practice Address - Country:US
Practice Address - Phone:314-526-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011033848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health