Healthcare Provider Details

I. General information

NPI: 1720578909
Provider Name (Legal Business Name): CARLISA SHAVON GILMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HURRICANE DR
JONESBORO AR
72401-4977
US

IV. Provider business mailing address

1600 ALDERSGATE RD STE 200
LITTLE ROCK AR
72205-6676
US

V. Phone/Fax

Practice location:
  • Phone: 870-910-3757
  • Fax:
Mailing address:
  • Phone: 501-661-0720
  • Fax: 501-325-7938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1806074
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: