Provider Demographics
NPI:1396946414
Name:SHELL, MICKEY K (MS)
Entity type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:K
Last Name:SHELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 GRIDER FIELD LADD RD
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601-9712
Mailing Address - Country:US
Mailing Address - Phone:870-535-5408
Mailing Address - Fax:
Practice Address - Street 1:3110 HWY 425 SOUTH
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601
Practice Address - Country:US
Practice Address - Phone:870-535-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR90-24E103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist