Provider Demographics
NPI:1730616343
Name:SHACKELFORD, KYWANNA (MA)
Entity type:Individual
Prefix:MRS
First Name:KYWANNA
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 KNIGHT ST
Mailing Address - Street 2:SUITE110
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2412
Mailing Address - Country:US
Mailing Address - Phone:918-670-7047
Mailing Address - Fax:318-670-7156
Practice Address - Street 1:2920 KNIGHT ST
Practice Address - Street 2:SUITE110
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2412
Practice Address - Country:US
Practice Address - Phone:918-670-7047
Practice Address - Fax:318-670-7156
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program