Provider Demographics
NPI:1649343070
Name:FLETCHER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 INNWOOD CIR STE A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2490
Mailing Address - Country:US
Mailing Address - Phone:501-954-7470
Mailing Address - Fax:501-954-7420
Practice Address - Street 1:2 INNWOOD CIR STE A
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2490
Practice Address - Country:US
Practice Address - Phone:501-954-7470
Practice Address - Fax:501-954-7420
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0095961101YM0800X
NM101YS0200X
ARA0903038221700000X, 101YM0800X
AR101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist