Basic Information
| Provider Information | |||||||||
| NPI: | 1124436530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELINGTON | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAUFFMAN | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144564013 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4171 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794437105 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 103TC2200X | 38772 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.