Provider Demographics
NPI:1265892087
Name:JOHN L. SHASTEEN LLC
Entity type:Organization
Organization Name:JOHN L. SHASTEEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHASTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:479-876-8626
Mailing Address - Street 1:1803 SW REGIONAL AIRPORT BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-8792
Mailing Address - Country:US
Mailing Address - Phone:479-876-8626
Mailing Address - Fax:479-876-8636
Practice Address - Street 1:1803 SW REGIONAL AIRPORT BLVD STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-8792
Practice Address - Country:US
Practice Address - Phone:479-876-8626
Practice Address - Fax:479-876-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-12851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR55196C466Medicare PIN