MEDICARE: MR. DANIEL WATKINS SHATTUCK PH.D., LCMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	3398	NC
2	101YM0800X	Mental Health Counselor	3398	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	E0478	OTHER	NC	MEDCOST PREFERRED
3	75888	OTHER	NC	BLUE CROSS AND BLUE SHIEL

General Provider Information

NPI Number	:	1558315820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL WATKINS SHATTUCK PH.D., LCMHC

Provider Business Mailing Address
First Line	:	2501 ATRIUM DR STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-6452
Country	:	US
Telephone Number	:	919-763-2760
Fax Number	:	919-359-9705

Provider Business Practice Location Address
First Line	:	2501 ATRIUM DR STE 100
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27607-6452
Country	:	US
Telephone Number	:	919-763-2760
Fax Number	:	919-359-9705

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	12/01/2021

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