Provider Demographics
NPI:1184358137
Name:SHIVE, ROBERT ALLEN III
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:SHIVE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 AUDUBON PARK LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6141
Mailing Address - Country:US
Mailing Address - Phone:601-906-3314
Mailing Address - Fax:
Practice Address - Street 1:141 TOWNSHIP AVE STE 303
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8699
Practice Address - Country:US
Practice Address - Phone:601-844-3884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty