MEDICARE: NORDIA SHACKELFORD LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904008972	VA
2	1041C0700X	Clinical Social Worker	077840	NY
3	1041C0700X	Clinical Social Worker	LW60765277	WA

General Provider Information

NPI Number	:	1932539681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NORDIA SHACKELFORD LICSW

Provider Business Mailing Address
First Line	:	3272 CALIFORNIA AVE SW STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-3375
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3272 CALIFORNIA AVE SW STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-3375
Country	:	US
Telephone Number	:	206-289-0438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2013
Last Update Date	:	01/03/2022

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