Basic Information
| Provider Information | |||||||||
| NPI: | 1689003147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEATHERLY | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2005 W ELM ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727584018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796360083 | ||||||||
| FaxNumber: | 4796360144 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 E CRANDALL AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726013628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707418484 | ||||||||
| FaxNumber: | 8707414088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2013 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P2107009 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 199054795 | 05 | AR | MEDICAID |