Basic Information
| Provider Information | |||||||||
| NPI: | 1023385358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC. - CRAWFORD COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WACGC - CRAWFORD SATS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11818 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794526650 | ||||||||
| FaxNumber: | 4797859495 | ||||||||
| Practice Location | |||||||||
| Address1: | 2705 OAK LN | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729564816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794526650 | ||||||||
| FaxNumber: | 4797859495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794526650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 188031744 | 05 | AR | MEDICAID |