Basic Information
| Provider Information | |||||||||
| NPI: | 1326215831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEATHERFORD | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 LINWOOD DR STE G | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724505365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706044455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1707 LINWOOD DR STE G | ||||||||
| Address2: | |||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724505365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706044455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2216-M | AR | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 2520-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 228173719 | 05 | AR | MEDICAID |