Healthcare Provider Details

I. General information

NPI: 1982361671
Provider Name (Legal Business Name): REFUGE AND RESTORE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 01/29/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4943 OLD GREENWOOD RD STE 9
FORT SMITH AR
72903-6923
US

IV. Provider business mailing address

2908 RIVERBEND DR
FORT SMITH AR
72903-5325
US

V. Phone/Fax

Practice location:
  • Phone: 479-353-0016
  • Fax:
Mailing address:
  • Phone: 379-353-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEANNA VITALE
Title or Position: AUTHORIZED OFFICIAL, SOLE OWNER
Credential: LCSW
Phone: 479-353-0016