Basic Information
| Provider Information | |||||||||
| NPI: | 1255605572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL PSYCHOLOGY FOR HEALTH AND PERFORMANCE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11347 HONEYSUCKLE RD | ||||||||
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| City: | OZARK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729499676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796671217 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 ROGERS AVE STE B | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729032986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792424560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 03/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | FAY | ||||||||
| AuthorizedOfficialFirstName: | ANITRA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4796671217 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 82-01P | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.