Provider Demographics
NPI:1215775580
Name:RALSTON, BAILEY (LAC)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:RALSTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-3915
Mailing Address - Country:US
Mailing Address - Phone:479-785-4083
Mailing Address - Fax:479-434-6248
Practice Address - Street 1:130 N COLLEGE AVE STE G
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5343
Practice Address - Country:US
Practice Address - Phone:479-785-4083
Practice Address - Fax:479-434-6248
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional