NPIMap

Organization Active NPI

Susan L Shackelford, PHD & Associates, PA

Doing business as Psychology & Counseling Associates

  • Clinical Psychologist
  • Fayetteville, AR
National Provider Identifier
1205976099
Registry record updated Apr 14, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
97-04P Issued in AR
Legal business name
SUSAN L SHACKELFORD, PHD & ASSOCIATES, PA
Doing business as
Psychology & Counseling Associates
Practice address
1 W Sunbridge Dr
Fayetteville, AR 72703-1825
Phone
(479) 443-5575
Fax
(479) 443-9554
NPI assigned
Feb 8, 2007
Last updated
Apr 14, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Lavonna M Latta
Title
Office Manager
Phone
(479) 443-5575

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 97-04P AR Primary

Addresses

Primary practice location

1 W Sunbridge Dr
Fayetteville, AR 72703-1825

Mailing address

1 W Sunbridge Dr
Fayetteville, AR 72703-1825
Phone (479) 443-5575

Other identifiers 1

IdentifierTypeStateIssuer
5T520OtherARBLUECROSS BLUESHIELD

Other names 1

  • Psychology & Counseling Associates Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120501000220 AR Part B Supplier - Clinic/Group Practice 8820071418 Receives reassigned benefits from 2 practitioners
Practice locations: Fayetteville, AR

National Provider Directory

National Provider Directory

Locations

5434 W Walsh Ln
Ste 100
Rogers, AR 72758
Phone (479) 442-2311

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1302739200000",
    "number": "1205976099",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 W SUNBRIDGE DR",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727031825",
            "telephone_number": "479-443-5575",
            "fax_number": "479-443-9554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 W SUNBRIDGE DR",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727031825",
            "telephone_number": "479-443-5575",
            "fax_number": "479-443-9554"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUSAN L SHACKELFORD, PHD & ASSOCIATES, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-08",
        "last_updated": "2011-04-14",
        "status": "A",
        "authorized_official_last_name": "LATTA",
        "authorized_official_first_name": "LAVONNA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "479-443-5575",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "AR",
            "license": "97-04P",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSS BLUESHIELD",
            "identifier": "5T520",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Psychology & Counseling Associates",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fayetteville, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.