Healthcare Provider Details

I. General information

NPI: 1073243085
Provider Name (Legal Business Name): KATHRYN M SHAFFER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 NE MCCLAIN RD BLDG 7
BENTONVILLE AR
72712-3875
US

IV. Provider business mailing address

9274 COMMONWEALTH RD
BENTONVILLE AR
72712-8892
US

V. Phone/Fax

Practice location:
  • Phone: 479-545-1545
  • Fax:
Mailing address:
  • Phone: 479-545-1545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2409007
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2208014
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: