Provider Demographics
NPI:1871963504
Name:LAFFERTY, SHELLEY CARROLL (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CARROLL
Last Name:LAFFERTY
Suffix:
Gender:F
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 1:3265 INTERTECH DR
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7325
Mailing Address - Country:US
Mailing Address - Phone:260-655-9494
Mailing Address - Fax:260-655-9496
Practice Address - Street 1:3265 INTERTECH DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-7325
Practice Address - Country:US
Practice Address - Phone:260-655-9494
Practice Address - Fax:260-655-9496
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3684G104100000X
IN34007993A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000014Medicaid