Basic Information
| Provider Information | |||||||||
| NPI: | 1588942833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASCENT CHS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHILD & YOUTH DEVELOPMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 S CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709359911 | ||||||||
| FaxNumber: | 8709353450 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709359911 | ||||||||
| FaxNumber: | 8709353450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | DEBBY | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8709359911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.