Healthcare Provider Details

I. General information

NPI: 1952570871
Provider Name (Legal Business Name): LORETTA J GEDOSH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E POPLAR ST
CLARKSVILLE AR
72830-4428
US

IV. Provider business mailing address

110 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

V. Phone/Fax

Practice location:
  • Phone: 479-754-8610
  • Fax: 479-754-8788
Mailing address:
  • Phone: 479-967-5570
  • Fax: 479-890-5364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: