Healthcare Provider Details

I. General information

NPI: 1801523980
Provider Name (Legal Business Name): CHRISTINE KODRICH QBHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HIGHWAY 62 412
ASH FLAT AR
72513-9594
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72405-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-7060
  • Fax:
Mailing address:
  • Phone: 870-933-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: