Basic Information
| Provider Information | |||||||||
| NPI: | 1689902256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 HIGHWAY 62 412 STE J | ||||||||
| Address2: | |||||||||
| City: | ASH FLAT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725139629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709947060 | ||||||||
| FaxNumber: | 8709947063 | ||||||||
| Practice Location | |||||||||
| Address1: | 1815 PLEASANT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 9709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2428-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5R661 | 01 | AR | BCBS | OTHER | 178890795 | 05 | AR | MEDICAID |