Provider Demographics
NPI:1871915413
Name:SHASTID, MARY KAY (ASW)
Entity type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:SHASTID
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 BEECH STREET
Mailing Address - Street 2:BUILDING 949
Mailing Address - City:MCCLELLAN
Mailing Address - State:CA
Mailing Address - Zip Code:95652
Mailing Address - Country:US
Mailing Address - Phone:517-614-2683
Mailing Address - Fax:
Practice Address - Street 1:3401 BEECH STREET
Practice Address - Street 2:BUILDING 949
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652
Practice Address - Country:US
Practice Address - Phone:517-614-2683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker