Provider Demographics
NPI:1225726797
Name:KOSHY, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:KOSHY
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 1:4440 W HAVANA AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-4049
Mailing Address - Country:US
Mailing Address - Phone:715-292-4329
Mailing Address - Fax:
Practice Address - Street 1:4440 W HAVANA AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-4049
Practice Address - Country:US
Practice Address - Phone:715-292-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8253-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker