Provider Demographics
NPI:1588969158
Name:PAGE, SHAWN (MHPP)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3687 HIGHWAY 17 S
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-9224
Mailing Address - Country:US
Mailing Address - Phone:870-869-1500
Mailing Address - Fax:870-869-1505
Practice Address - Street 1:609 W 3RD ST
Practice Address - Street 2:
Practice Address - City:IMBODEN
Practice Address - State:AR
Practice Address - Zip Code:72434-9099
Practice Address - Country:US
Practice Address - Phone:870-869-1500
Practice Address - Fax:870-869-1505
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169075795Medicaid