Provider Demographics
NPI:1932823358
Name:MORMON, SHANTE (LCSW, C-DBT)
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:MORMON
Suffix:
Gender:F
Credentials:LCSW, C-DBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5518 PALISADES CV
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-8573
Mailing Address - Country:US
Mailing Address - Phone:330-807-6045
Mailing Address - Fax:
Practice Address - Street 1:685 SHELBY TRL STE 105
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7169
Practice Address - Country:US
Practice Address - Phone:501-300-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5030-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical