Basic Information
Provider Information | |||||||||
NPI: | 1467485680 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TEXARKANA BEHAVIORAL ASSOCIATES LC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VISTA HEALTH TEXARKANA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4253 N CROSSOVER RD | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727034593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795215731 | ||||||||
FaxNumber: | 4795214926 | ||||||||
Practice Location | |||||||||
Address1: | 801 ARKANSAS BLVD | ||||||||
Address2: |   | ||||||||
City: | TEXARKANA | ||||||||
State: | AR | ||||||||
PostalCode: | 718542107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795215731 | ||||||||
FaxNumber: | 4795214926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BORENGASSER | ||||||||
AuthorizedOfficialFirstName: | CONNIE | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4795215731 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | PENDING | AR | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | AR |   | MEDICAID | PENDING | 05 | TX |   | MEDICAID | PENDING | 01 | AR | BLUE CROSS | OTHER |