Basic Information
| Provider Information | |||||||||
| NPI: | 1053364612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA COUNSELING ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716555723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703679732 | ||||||||
| FaxNumber: | 8704606133 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716555723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703672461 | ||||||||
| FaxNumber: | 8704606133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAYNIE | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO ELECT | ||||||||
| AuthorizedOfficialTelephone: | 8703672461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 116387726 | 05 | AR | MEDICAID |