Healthcare Provider Details

I. General information

NPI: 1346463353
Provider Name (Legal Business Name): CORNERSTONE COMMUNITY COUNSELING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W 3RD ST
IMBODEN AR
72434-9099
US

IV. Provider business mailing address

609 W 3RD ST
IMBODEN AR
72434-9099
US

V. Phone/Fax

Practice location:
  • Phone: 870-869-1500
  • Fax: 870-869-1505
Mailing address:
  • Phone: 870-869-1500
  • Fax: 870-869-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRENDA MARIE RAY
Title or Position: CEO
Credential: MRC, LPC
Phone: 870-869-1500