Provider Demographics
NPI:1194872168
Name:SHACKELFORD, MICHELE DEE (PHD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:DEE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 54TH ST
Mailing Address - Street 2:APT. 33B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5179
Mailing Address - Country:US
Mailing Address - Phone:917-322-0455
Mailing Address - Fax:
Practice Address - Street 1:1430 2ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3313
Practice Address - Country:US
Practice Address - Phone:212-434-4594
Practice Address - Fax:212-717-5691
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005459103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist