Provider Demographics
NPI:1093148249
Name:SHAVERS, GELETTA PHILAE
Entity Type:Individual
Prefix:MS
First Name:GELETTA
Middle Name:PHILAE
Last Name:SHAVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ALDERSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:
Practice Address - Street 1:105 COX ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4611
Practice Address - Country:US
Practice Address - Phone:501-906-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
AR8360C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program