Healthcare Provider Details

I. General information

NPI: 1770217242
Provider Name (Legal Business Name): DESIREE BALTAZAR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N EAST ST
BENTON AR
72015-3327
US

IV. Provider business mailing address

910 N EAST ST
BENTON AR
72015-3327
US

V. Phone/Fax

Practice location:
  • Phone: 501-381-2001
  • Fax: 501-381-2005
Mailing address:
  • Phone: 501-381-2001
  • Fax: 501-381-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12109-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12109-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: