Basic Information
| Provider Information | |||||||||
| NPI: | 1780765768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STREETT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2153 E JOYCE BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795759471 | ||||||||
| FaxNumber: | 4795879392 | ||||||||
| Practice Location | |||||||||
| Address1: | 706 S MAIN ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726534417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704255644 | ||||||||
| FaxNumber: | 8704242201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1768C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 55048 | 01 | MEDICARE ID NUMBER | OTHER |