Basic Information
Provider Information | |||||||||
NPI: | 1326040692 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11818 | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729171818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794526650 | ||||||||
FaxNumber: | 4794525847 | ||||||||
Practice Location | |||||||||
Address1: | 3111 S 70TH ST | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729035017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794526650 | ||||||||
FaxNumber: | 4794525847 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 02/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLWICK | ||||||||
AuthorizedOfficialFirstName: | AARON | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4794526650 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPE-I | ||||||||
NPICertificationDate: | 02/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   | AR | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 116380726 | 05 | AR |   | MEDICAID | 155700125 | 05 | AR |   | MEDICAID |