Basic Information
| Provider Information | |||||||||
| NPI: | 1326299736 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MID-SOUTH HEALTH SYSTEMS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708867924 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 SOUTH LARKSPUR | ||||||||
| Address2: | |||||||||
| City: | WALNUT RIDGE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724761736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708867924 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYERLY | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8709724939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 172107526 | 05 | AR | MEDICAID |