Healthcare Provider Details

I. General information

NPI: 1912941220
Provider Name (Legal Business Name): FORDYCE COUNSELING CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W 3RD ST
FORDYCE AR
71742-3014
US

IV. Provider business mailing address

1101 W 3RD ST
FORDYCE AR
71742-3014
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-5122
  • Fax: 870-352-5127
Mailing address:
  • Phone: 870-352-5122
  • Fax: 870-352-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL LOYD MOORE
Title or Position: PRESIDENT
Credential: M.S., L.A.C.
Phone: 870-352-5122