Basic Information
Provider Information | |||||||||
NPI: | 1598915514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHWEST ARKANSAS COUNSELING AND MENTAL HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2904 ARKANSAS BLVD | ||||||||
Address2: |   | ||||||||
City: | TEXARKANA | ||||||||
State: | AR | ||||||||
PostalCode: | 718542536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707734655 | ||||||||
FaxNumber: | 8707724650 | ||||||||
Practice Location | |||||||||
Address1: | 1658 HIGHWAY 371 WEST | ||||||||
Address2: |   | ||||||||
City: | PRESCOTT | ||||||||
State: | AR | ||||||||
PostalCode: | 71857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708873660 | ||||||||
FaxNumber: | 8708873705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2008 | ||||||||
LastUpdateDate: | 09/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WORLEY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8707734655 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 137644726 | 05 | AR |   | MEDICAID |