Basic Information
Provider Information | |||||||||
NPI: | 1538191275 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HECKLE | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILSON | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11818 | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729171818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794526650 | ||||||||
FaxNumber: | 4794525847 | ||||||||
Practice Location | |||||||||
Address1: | 3111 S 70TH ST | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729035017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794526650 | ||||||||
FaxNumber: | 4794525847 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 01/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1389-C | AR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 5U352 | 01 | AR | BLUE CROSS | OTHER | 50917000000 | 01 | AR | QUALCHOICE | OTHER |