Basic Information
| Provider Information | |||||||||
| NPI: | 1912941220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORDYCE COUNSELING CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717423014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703525122 | ||||||||
| FaxNumber: | 8703525127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717423014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703525122 | ||||||||
| FaxNumber: | 8703525127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | LOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8703525122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.S., L.A.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.