Basic Information
| Provider Information | |||||||||
| NPI: | 1245675396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANKLE | ||||||||
| FirstName: | TABATHA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638341030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736831211 | ||||||||
| FaxNumber: | 8663124304 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638341632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5731471080 | ||||||||
| FaxNumber: | 5734710810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2013 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2012011602 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2014030736 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.