Provider Demographics
NPI:1699247064
Name:SHACKS-GLOVER, LENA (LMSW)
Entity type:Individual
Prefix:MS
First Name:LENA
Middle Name:
Last Name:SHACKS-GLOVER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 DELTA RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9340
Mailing Address - Country:US
Mailing Address - Phone:989-778-2276
Mailing Address - Fax:
Practice Address - Street 1:2355 DELTA RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9340
Practice Address - Country:US
Practice Address - Phone:989-778-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56801093219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health