Healthcare Provider Details

I. General information

NPI: 1497193114
Provider Name (Legal Business Name): BRYAN WHITE CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WHITTINGTON AVE
HOT SPRINGS AR
71901-3407
US

IV. Provider business mailing address

311 WHITTINGTON AVE
HOT SPRINGS AR
71901-3407
US

V. Phone/Fax

Practice location:
  • Phone: 501-623-3477
  • Fax: 501-624-7498
Mailing address:
  • Phone: 501-623-3477
  • Fax: 501-624-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1481
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: