Provider Demographics
NPI:1083761464
Name:SHADE, DAVID A (MS, LPE-I)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:SHADE
Suffix:
Gender:M
Credentials:MS, LPE-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR83-13EI103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198883795Medicaid
AR5A020OtherBCBS
AR198883795Medicaid