Basic Information
Provider Information | |||||||||
NPI: | 1992927255 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIFFITH | ||||||||
FirstName: | CHARLOTTE | ||||||||
MiddleName: | BLANKENSHIP | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRIFFITH | ||||||||
OtherFirstName: | CHARLEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2707 BROWNS LN | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724017213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709724000 | ||||||||
FaxNumber: | 8709340847 | ||||||||
Practice Location | |||||||||
Address1: | 2707 BROWNS LN | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724017213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8709724000 | ||||||||
FaxNumber: | 8709340847 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 04/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | P0604025 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 169283795 | 05 | AR |   | MEDICAID |