Provider Demographics
NPI:1124337779
Name:HEMSTROM, SHAKIRAH C (LPC)
Entity type:Individual
Prefix:
First Name:SHAKIRAH
Middle Name:C
Last Name:HEMSTROM
Suffix:
Gender:F
Credentials:LPC
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 1082
Mailing Address - Street 2:
Mailing Address - City:AULT
Mailing Address - State:CO
Mailing Address - Zip Code:80610-1082
Mailing Address - Country:US
Mailing Address - Phone:970-302-4667
Mailing Address - Fax:
Practice Address - Street 1:216 1ST ST
Practice Address - Street 2:UNIT F
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-3477
Practice Address - Country:US
Practice Address - Phone:970-302-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3704101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO636875Medicaid