Healthcare Provider Details

I. General information

NPI: 1205805116
Provider Name (Legal Business Name): PHILIP C PACKARD ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N COLLEGE AVE
EL DORADO AR
71730-4403
US

IV. Provider business mailing address

715 N COLLEGE AVE
EL DORADO AR
71730-4403
US

V. Phone/Fax

Practice location:
  • Phone: 870-862-7921
  • Fax: 870-864-2490
Mailing address:
  • Phone: 870-862-7921
  • Fax: 870-864-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number210-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: