MEDICARE: CLINICAL PSYCHOLOGY FOR HEALTH AND PERFORMANCE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	82-01P	AR

General Provider Information

NPI Number	:	1255605572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICAL PSYCHOLOGY FOR HEALTH AND PERFORMANCE PA

Provider Business Mailing Address
First Line	:	11347 HONEYSUCKLE RD
Second Line	:
City	:	OZARK
State	:	AR
Zip	:	72949-9676
Country	:	US
Telephone Number	:	479-667-1217
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 ROGERS AVE STE B
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-2986
Country	:	US
Telephone Number	:	479-242-4560
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANITRA S. FAY
Credential	:	PH.D.
Telephone Number	:	479-667-1217

Provider Enumeration Date	:	03/05/2012
Last Update Date	:	03/05/2012

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