Provider Demographics
NPI:1063898989
Name:HERRON, SHANECE
Entity type:Individual
Prefix:
First Name:SHANECE
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 MERRILL DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4009
Mailing Address - Country:US
Mailing Address - Phone:501-663-2199
Mailing Address - Fax:
Practice Address - Street 1:1 LILE CT STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6240
Practice Address - Country:US
Practice Address - Phone:501-663-1837
Practice Address - Fax:501-663-1839
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ARP2209002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209306795Medicaid