Provider Demographics
NPI:1134522667
Name:FORTUNE, SHAY M (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHAY
Middle Name:M
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 LONGTREE CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-1909
Mailing Address - Country:US
Mailing Address - Phone:501-350-1008
Mailing Address - Fax:
Practice Address - Street 1:4207 LONGTREE CV
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-1909
Practice Address - Country:US
Practice Address - Phone:501-350-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR135061721Medicaid