Provider Demographics
NPI:1811418973
Name:GADBERRY, SHONDA M (DT)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:M
Last Name:GADBERRY
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2725
Mailing Address - Country:US
Mailing Address - Phone:479-968-1198
Mailing Address - Fax:479-967-1178
Practice Address - Street 1:500 E 3RD ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5204
Practice Address - Country:US
Practice Address - Phone:479-968-5048
Practice Address - Fax:479-968-5048
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200209778Medicaid