Basic Information
| Provider Information | |||||||||
| NPI: | 1477682649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXARKANA BEHAVIORAL ASSOCIATES LC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISTA HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4253 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795215731 | ||||||||
| FaxNumber: | 4795214926 | ||||||||
| Practice Location | |||||||||
| Address1: | 3352 N FUTRALL DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794436496 | ||||||||
| FaxNumber: | 4795214926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BORENGASSER | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4795215731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
No ID Information.