Basic Information
Provider Information | |||||||||
NPI: | 1609254515 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAKIR | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | HOLLOWAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 65 E SUNBRIDGE DR | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727032894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794339707 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 W WALNUT ST | ||||||||
Address2: | SUITE 1400 | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727563521 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797256000 | ||||||||
FaxNumber: | 4797504843 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2015 | ||||||||
LastUpdateDate: | 03/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1505065 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.