Healthcare Provider Details

I. General information

NPI: 1043896913
Provider Name (Legal Business Name): CATHERINE KABASIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 E MOUNTAIN ST STE 12
FAYETTEVILLE AR
72701-6067
US

IV. Provider business mailing address

19 E MOUNTAIN ST STE 12
FAYETTEVILLE AR
72701-6067
US

V. Phone/Fax

Practice location:
  • Phone: 479-601-7577
  • Fax:
Mailing address:
  • Phone: 479-601-7577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE DIMAKATSO KABASIA-SELLO
Title or Position: THERAPIST/OWNER
Credential: LCSW
Phone: 479-601-7577