Healthcare Provider Details

I. General information

NPI: 1275945586
Provider Name (Legal Business Name): SHAWN KNADLER PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP, BLDG5445
JBSA-LACKLAND AFB TX
78236-9908
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 5445
JBSA LACKLAND TX
78236-9908
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-6225
  • Fax:
Mailing address:
  • Phone: 219-292-6225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0004761
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: