Basic Information
| Provider Information | |||||||||
| NPI: | 1457733099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR PSYCHIATRIC WELLNESS, PLLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11137 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171137 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7217 CAMERON PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798316007 | ||||||||
| FaxNumber: | 4797821242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2015 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | OBANA | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4798316007 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | E-7817 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 210878002 | 05 | AR | MEDICAID |