Basic Information
| Provider Information | |||||||||
| NPI: | 1649343070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | SHANNON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 INNWOOD CIR STE A | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019547470 | ||||||||
| FaxNumber: | 5019547420 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 INNWOOD CIR STE A | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722112490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019547470 | ||||||||
| FaxNumber: | 5019547420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0095961 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YS0200X | NM | N | Behavioral Health & Social Service Providers | Counselor | School | 221700000X | A0903038 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist | 101YS0200X | AR | N | Behavioral Health & Social Service Providers | Counselor | School | 101YM0800X | A0903038 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.