=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235214024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES RUSSELL SHAFFAR MSW, LISW, CSAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 07/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | USAG VICENZA CMR 427 BOX 1548
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 011390444717554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | USAG VICENZA CMR 427 BOX 1548
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09630-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1183-03R
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180-004212
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I0600061
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------