| Doctor Name: | DR. SHANE SHACKFORD |
| NPI Number: | 1134405533 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PSY.D |
| License Number: | 2516 |
| Business Practice Address: | 325 E Jimmie Leeds Rd Suite 182 Galloway, NJ - 082054126 |
| Business Phone Number: | 6093258775 |
| Business Fax Number: | |
| Mailing Address: | 325 E Jimmie Leeds Rd, Suite 182 GALLOWAY |
| State: | NJ |
| Postal Code: | 082054126 |
| Phone Number: | 6093258775 |
| Fax Number: | |
| NPI Enumeration Date: | 10/29/2011 |
| NPI Last Update Date: | 10/29/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TS0200X |
| License Number: | 2516 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |