Healthcare Provider Details

I. General information

NPI: 1124744917
Provider Name (Legal Business Name): CAPPS WELLNESS CLINIC AND ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S PINE ST
HARRISON AR
72601-5827
US

IV. Provider business mailing address

623 S PINE ST
HARRISON AR
72601-5827
US

V. Phone/Fax

Practice location:
  • Phone: 501-278-6688
  • Fax: 870-204-5306
Mailing address:
  • Phone: 501-278-6688
  • Fax: 870-204-5306

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. ACACIA LYNETTE JOHNSON
Title or Position: THERAPIST
Credential: ED.S., LPC
Phone: 501-278-6688