Healthcare Provider Details

I. General information

NPI: 1568763530
Provider Name (Legal Business Name): CATHERINE ELIZABETH PETTUS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 CORPORATE CTR
BRYANT AR
72022-9252
US

IV. Provider business mailing address

3005 CORPORATE CTR
BRYANT AR
72022-9252
US

V. Phone/Fax

Practice location:
  • Phone: 501-512-2080
  • Fax:
Mailing address:
  • Phone: 501-512-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3194-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: