Provider Demographics
NPI:1316432966
Name:MID STATE COUNSELING AND RECOVERY SERVICE
Entity type:Organization
Organization Name:MID STATE COUNSELING AND RECOVERY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEON
Authorized Official - Middle Name:L
Authorized Official - Last Name:AARON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:501-413-8977
Mailing Address - Street 1:1920 MAIN ST STE 229
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2875
Mailing Address - Country:US
Mailing Address - Phone:501-413-8977
Mailing Address - Fax:501-246-4407
Practice Address - Street 1:1920 MAIN ST STE 229
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114
Practice Address - Country:US
Practice Address - Phone:501-413-8977
Practice Address - Fax:501-246-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3000-C261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health