Basic Information
| Provider Information | |||||||||
| NPI: | 1558727024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESTORED LIFE SERVICES OF ARKANSAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESTORED LIFE SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1483 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728111483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792194100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 127 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728015106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792194100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONNER | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | CAITLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4792194100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | L.A.D.A.C., C.R.C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.