Provider Demographics
NPI:1932823358
Name:MORMON, SHANTE (LCSW, C-DBT, CGP)
Entity type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:MORMON
Suffix:
Gender:F
Credentials:LCSW, C-DBT, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1283
Mailing Address - Country:US
Mailing Address - Phone:501-209-7522
Mailing Address - Fax:
Practice Address - Street 1:400 W CAPITOL AVE STE 1700
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3438
Practice Address - Country:US
Practice Address - Phone:501-209-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5030-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical