1144465139 NPI number — MS. SAMANTHA SEWELL SHORT PSYD, LP

Table of content: MS. SAMANTHA SEWELL SHORT PSYD, LP (NPI 1144465139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144465139 NPI number — MS. SAMANTHA SEWELL SHORT PSYD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORT
Provider First Name:
SAMANTHA
Provider Middle Name:
SEWELL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PSYD, LP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBINSON
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144465139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 OAK ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-5679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-291-3091
Provider Business Mailing Address Fax Number:
501-588-0484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 OAK ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-5679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-358-6396
Provider Business Practice Location Address Fax Number:
501-588-0484
Provider Enumeration Date:
12/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  15-11P , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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