Healthcare Provider Details

I. General information

NPI: 1205388071
Provider Name (Legal Business Name): IMPACT COUNSELING CLINIC, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 MAIN AVE
DIERKS AR
71833-9421
US

IV. Provider business mailing address

PO BOX 575
DIERKS AR
71833-0575
US

V. Phone/Fax

Practice location:
  • Phone: 870-285-1413
  • Fax: 870-825-2060
Mailing address:
  • Phone: 870-285-1413
  • Fax: 870-825-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. PRISCILLA ANN FAULKNER
Title or Position: CEO
Credential: LPC
Phone: 870-285-1413