Provider Demographics
NPI:1932465119
Name:ROBERTS, SHIRLEY G (MHPP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:G
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:
Other - Last Name:GILLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHPP
Mailing Address - Street 1:4001 COMMERCIAL CENTER DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-9616
Mailing Address - Country:US
Mailing Address - Phone:870-735-4441
Mailing Address - Fax:870-735-5441
Practice Address - Street 1:4001 COMMERCIAL CENTER DR STE 2
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9616
Practice Address - Country:US
Practice Address - Phone:870-735-4441
Practice Address - Fax:870-735-5441
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator