Basic Information
| Provider Information | |||||||||
| NPI: | 1255757324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDON | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 335 | ||||||||
| Address2: | 363 STOKENBURY ROAD | ||||||||
| City: | ELKINS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727270335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792009426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 823 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707412960 | ||||||||
| FaxNumber: | 8707412965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 158658526 | 05 | AR | MEDICAID |