Healthcare Provider Details

I. General information

NPI: 1598684979
Provider Name (Legal Business Name): LUKE SHACKELFORD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4182 N VIKING WAY STE 202
LONG BEACH CA
90808-1476
US

IV. Provider business mailing address

2451 GREGORY LN
LA HABRA CA
90631-3516
US

V. Phone/Fax

Practice location:
  • Phone: 562-566-4257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: