Basic Information
| Provider Information | |||||||||
| NPI: | 1083937858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KILGORE | ||||||||
| OtherFirstName: | CONNIE | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3352 N FUTRALL DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211427 | ||||||||
| FaxNumber: | 4795216520 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 E CRANDALL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726013628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707418484 | ||||||||
| FaxNumber: | 8707414088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2010 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2430C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.