Provider Demographics
NPI:1174068217
Name:SHACKELFORD, MARIE THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESA
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N ROBBINS RD
Mailing Address - Street 2:ST LUKE'S REHAB HOSPITAL
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-385-3245
Mailing Address - Fax:208-489-4053
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-385-3245
Practice Address - Fax:208-489-4053
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW360421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical