Provider Demographics
NPI:1073977476
Name:KUYKENDALL, SHEALTIEL BLU (LCSW)
Entity Type:Individual
Prefix:
First Name:SHEALTIEL
Middle Name:BLU
Last Name:KUYKENDALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEVI
Other - Middle Name:BLU
Other - Last Name:KUYKENDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:1233 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4245
Mailing Address - Country:US
Mailing Address - Phone:479-636-9235
Mailing Address - Fax:479-631-0374
Practice Address - Street 1:3708 AMBERWOOD ST.
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-633-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6690-M104100000X
AR6690-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker