Provider Demographics
NPI:1447308507
Name:SHAFFNER, RANDY G (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:G
Last Name:SHAFFNER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E MONUMENT ST STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1062
Mailing Address - Country:US
Mailing Address - Phone:719-633-7819
Mailing Address - Fax:719-477-9692
Practice Address - Street 1:128 E MONUMENT ST STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1062
Practice Address - Country:US
Practice Address - Phone:719-633-7819
Practice Address - Fax:719-477-9692
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9840771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO056368Medicaid