Basic Information
| Provider Information | |||||||||
| NPI: | 1598058489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDSOUTH HEALTH SYSTEMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724939 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723012001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707354511 | ||||||||
| FaxNumber: | 8707355260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYERLY | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8709724939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 18417774 | 05 | AR | MEDICAID |