Provider Demographics
NPI:1174611347
Name:SHAFFER, KATHALEEN MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KATHALEEN
Middle Name:MARIE
Last Name:SHAFFER
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 1:4005 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE A200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759
Mailing Address - Country:US
Mailing Address - Phone:512-407-8646
Mailing Address - Fax:
Practice Address - Street 1:4005 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE A200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759
Practice Address - Country:US
Practice Address - Phone:512-407-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS156881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX581ZOtherBLUE CROSS BLUE SHIELD
TX612250Medicare ID - Type Unspecified