Provider Demographics
NPI:1609559137
Name:SHINKLE, BROCK (LAC)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:
Last Name:SHINKLE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21019 HIGHWAY 16 E
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-5381
Mailing Address - Country:US
Mailing Address - Phone:865-776-6806
Mailing Address - Fax:
Practice Address - Street 1:21019 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-5381
Practice Address - Country:US
Practice Address - Phone:865-776-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2206018101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health