Basic Information
| Provider Information | |||||||||
| NPI: | 1720578909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMER | ||||||||
| FirstName: | CARLISA | ||||||||
| MiddleName: | SHAVON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 HURRICANE DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709103757 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2018 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AR | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | A1806074 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.