Healthcare Provider Details

I. General information

NPI: 1144417171
Provider Name (Legal Business Name): ADAM NICHOLAS MAISEN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 02/10/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 CLINTON ST STE B
ARKADELPHIA AR
71923-5924
US

IV. Provider business mailing address

812 CLINTON ST STE B
ARKADELPHIA AR
71923-5924
US

V. Phone/Fax

Practice location:
  • Phone: 870-293-2054
  • Fax: 870-464-1073
Mailing address:
  • Phone: 870-293-2054
  • Fax: 870-464-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP10100171
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1010071
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: