Healthcare Provider Details

I. General information

NPI: 1326530585
Provider Name (Legal Business Name): SACRED TRUST CHRISTIAN COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 SIMMS ST
CONWAY AR
72034-6416
US

IV. Provider business mailing address

PO BOX 2431
CONWAY AR
72033-2431
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-4564
  • Fax: 410-449-6336
Mailing address:
  • Phone: 800-395-4564
  • Fax: 410-449-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number121001
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number121001
License Number StateOH

VIII. Authorized Official

Name: DR. CASONDRA RENEE ROBINSON
Title or Position: CEO
Credential: PHD, THD
Phone: 800-395-4564