1871039883 NPI number — SYSTEMIC FAMILY THERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871039883 NPI number — SYSTEMIC FAMILY THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYSTEMIC FAMILY THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871039883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 897
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72018-0897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-400-6570
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17724 I 30 STE 2 OFC 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72019-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-400-6570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WALLIS
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
RUGGIERO
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
501-400-6570

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  PO807061 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 305R00000X , with the licence number: MO704002 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1699966697 . This is a "NPI" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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