Basic Information
| Provider Information | |||||||||
| NPI: | 1356521553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWARD | ||||||||
| FirstName: | SHANTINA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 LAFAYETTE 39 | ||||||||
| Address2: | |||||||||
| City: | BUCKNER | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718279505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709530045 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 626 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718458502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709213800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | R72626 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.