Basic Information
| Provider Information | |||||||||
| NPI: | 1316023591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC. - CSU/CRI | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WACGC - HORIZON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11818 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794526650 | ||||||||
| FaxNumber: | 4797859495 | ||||||||
| Practice Location | |||||||||
| Address1: | 3113 S 70TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729035017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794526650 | ||||||||
| FaxNumber: | 4797859495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | HOLWICK | ||||||||
| AuthorizedOfficialFirstName: | RUSTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794526650 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPEI | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 155700125 | 05 | AR | MEDICAID |