Basic Information
| Provider Information | |||||||||
| NPI: | 1861680852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTSON | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | DELEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPE-I | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICKETT | ||||||||
| OtherFirstName: | SHARON | ||||||||
| OtherMiddleName: | DELEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 S FILLMORE ST | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722044909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019064909 | ||||||||
| FaxNumber: | 5012961714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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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 | 12-02EI | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.