Basic Information
| Provider Information | |||||||||
| NPI: | 1992130918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
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| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4171 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211427 | ||||||||
| FaxNumber: | 4795216520 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 ARKANSAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707725028 | ||||||||
| FaxNumber: | 8707725056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.