Healthcare Provider Details

I. General information

NPI: 1801345921
Provider Name (Legal Business Name): NICKOLAS BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 MAIN ST
CONWAY AR
72032-5426
US

IV. Provider business mailing address

1022 MAIN ST
CONWAY AR
72032-5426
US

V. Phone/Fax

Practice location:
  • Phone: 501-609-0400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2108000
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: