Provider Demographics
NPI:1598864043
Name:NW ARKANSAS PSYCHOLOGICAL GROUP INC
Entity type:Organization
Organization Name:NW ARKANSAS PSYCHOLOGICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:479-442-9381
Mailing Address - Street 1:1706 E JOYCE BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-442-9381
Mailing Address - Fax:479-442-9396
Practice Address - Street 1:1706 E JOYCE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5238
Practice Address - Country:US
Practice Address - Phone:479-442-9381
Practice Address - Fax:479-442-9396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR78-18 P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F628Medicare UPIN
5F628Medicare PIN