Healthcare Provider Details

I. General information

NPI: 1396247474
Provider Name (Legal Business Name): SHATOYIA MONIQUE STOVALL LCSW, LICSW, LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 CYPRESS AVE
CLARKSDALE MS
38614-2610
US

IV. Provider business mailing address

424 CYPRESS AVE
CLARKSDALE MS
38614-2610
US

V. Phone/Fax

Practice location:
  • Phone: 662-645-9069
  • Fax:
Mailing address:
  • Phone: 662-645-9069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8791C
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number06518
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC11967
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33036
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: