Basic Information
| Provider Information | |||||||||
| NPI: | 1285954339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDS FOR THE FUTURE OF MARIANNA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W MAIN ST | ||||||||
| Address2: | PO BOX 1102 | ||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723602102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702955280 | ||||||||
| FaxNumber: | 8702955390 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723602102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702955280 | ||||||||
| FaxNumber: | 8702955390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | HEISLER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8702955280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 14012 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 235Z00000X | 14012 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 252Y00000X | 14012 | AR | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 181131724 | 05 | AR | MEDICAID |