Healthcare Provider Details

I. General information

NPI: 1699053835
Provider Name (Legal Business Name): GLENDA SHAVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 BRAGG ST
WARREN AR
71671-2500
US

IV. Provider business mailing address

1 CHILDRENS WAY SLOT 900
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 870-226-7844
  • Fax: 870-226-2798
Mailing address:
  • Phone: 501-364-3620
  • Fax: 501-364-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: