Healthcare Provider Details

I. General information

NPI: 1215474614
Provider Name (Legal Business Name): CARLA M. SHAFFER, PHD., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E MAIN ST #3
RICHMOND VA
23219-2109
US

IV. Provider business mailing address

3649 STONE HARBOR DR
MIDLOTHIAN VA
23113-9200
US

V. Phone/Fax

Practice location:
  • Phone: 804-495-0676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005414
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0810005414
License Number StateVA

VIII. Authorized Official

Name: DR. CARLA SHAFFER
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PHD., LCP
Phone: 804-873-8755