Active NPI
Bruce Warner Shackleton, ED.D.
- Clinical Psychologist
- Wayland, MA
National Provider Identifier
1750474383
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 2621
- Practice address
- 35 Main Street #3
Wayland, MA 01778 - Phone
- (508) 655-6322
- Fax
- (508) 655-9793
- NPI assigned
- Oct 2, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 2621 | MA | Primary |
| Psychologist | 103T00000X | 2621 | MA |
Addresses
Primary practice location
35 Main Street #3
Wayland, MA 01778
Mailing address
Post Office Box 5232
Wayland, MA 01778
Phone (508) 655-6322
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2621 | MA | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159747200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1267142400000",
"number": "1750474383",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "POST OFFICE BOX 5232",
"city": "WAYLAND",
"state": "MA",
"postal_code": "01778",
"telephone_number": "508-655-6322",
"fax_number": "508-655-9793"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "35 MAIN STREET #3",
"city": "WAYLAND",
"state": "MA",
"postal_code": "01778",
"telephone_number": "508-655-6322",
"fax_number": "508-655-9793"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHACKLETON",
"first_name": "BRUCE",
"middle_name": "WARNER",
"name_prefix": "Dr.",
"credential": "ED.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-02",
"last_updated": "2010-02-26",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MA",
"license": "2621",
"primary": true
},
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MA",
"license": "2621",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Wayland, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.