Provider Demographics
NPI:1992120687
Name:MOUTRY, SHATOBECA
Entity type:Individual
Prefix:MRS
First Name:SHATOBECA
Middle Name:
Last Name:MOUTRY
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:PO BOX 6625
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71611-6625
Mailing Address - Country:US
Mailing Address - Phone:870-872-0187
Mailing Address - Fax:
Practice Address - Street 1:204 FRANKIE LN
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-2699
Practice Address - Country:US
Practice Address - Phone:870-247-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator