Provider Demographics
NPI:1871525071
Name:SHASTEEN, JOHN LARK (LCSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LARK
Last Name:SHASTEEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 SW REGIONAL AIRPORT BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-8792
Mailing Address - Country:US
Mailing Address - Phone:479-876-8626
Mailing Address - Fax:479-876-8636
Practice Address - Street 1:1803 SW REGIONAL AIRPORT BLVD STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-8792
Practice Address - Country:US
Practice Address - Phone:479-876-8626
Practice Address - Fax:479-876-8636
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-12851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S196OtherBLUE SHIELD PROVIDER #