Basic Information
| Provider Information | |||||||||
| NPI: | 1457515108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | NARISSA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUTCHINSON | ||||||||
| OtherFirstName: | NARISSA | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5401 ROGERS AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792424560 | ||||||||
| FaxNumber: | 4792424561 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 ROGERS AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792424560 | ||||||||
| FaxNumber: | 4792424561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 11-21P | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 190433719 | 05 | AR | MEDICAID |