Healthcare Provider Details

I. General information

NPI: 1235214024
Provider Name (Legal Business Name): JAMES RUSSELL SHAFFAR MSW, LISW, CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAG VICENZA CMR 427 BOX 1548
APO AE
09630
US

IV. Provider business mailing address

USAG VICENZA CMR 427 BOX 1548
APO AE
09630-0000
US

V. Phone/Fax

Practice location:
  • Phone: 011390444717554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1183-03R
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-004212
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0600061
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: