Provider Demographics
NPI:1982443784
Name:SHAKESPEAR, CLARISSA NICOLE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:NICOLE
Last Name:SHAKESPEAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SHAKESPEARE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:59 FOX CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-9339
Mailing Address - Country:US
Mailing Address - Phone:334-778-2611
Mailing Address - Fax:
Practice Address - Street 1:59 FOX CHASE DR
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-9339
Practice Address - Country:US
Practice Address - Phone:334-778-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician