Provider Demographics
NPI:1073581468
Name:SOUHEAVER, GARY T (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:T
Last Name:SOUHEAVER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MARGEAUX CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9193
Mailing Address - Country:US
Mailing Address - Phone:501-868-4933
Mailing Address - Fax:501-868-4077
Practice Address - Street 1:6 MARGEAUX CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-9193
Practice Address - Country:US
Practice Address - Phone:501-868-4933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7825P103G00000X, 103T00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56348Medicare ID - Type Unspecified