Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | NLC 0103280 | CO |
NPI | 1265980981 |
---|---|
Provider Name | Karl Shackelford |
First Address | Evergreen, CO 80439-4338 |
Second Address | Thornton, CO 80229-4358 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2016 |
Last Update Date | 12/09/2016 |