Provider Demographics
NPI:1447849799
Name:SHACKELFORD, CHANDA F
Entity type:Individual
Prefix:
First Name:CHANDA
Middle Name:F
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0618
Mailing Address - Country:US
Mailing Address - Phone:530-243-7470
Mailing Address - Fax:530-243-7477
Practice Address - Street 1:1237 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0618
Practice Address - Country:US
Practice Address - Phone:530-243-7470
Practice Address - Fax:530-243-7477
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11367101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)