Individual
SHAUNA HACKEROTT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2420 24TH ST, GREAT BEND, KS 67530-2428
(620) 899-4828
Mailing address
971 E WICHITA AVE, RUSSELL, KS 67665-2444
(620) 899-4828
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22269
22269
KS
Enumeration date
11/08/2019
Last updated
11/08/2019
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