Healthcare Provider Details

I. General information

NPI: 1356855324
Provider Name (Legal Business Name): CIVILPSYCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 COUNTY ROAD 7593
JONESBORO AR
72401-7764
US

IV. Provider business mailing address

484 COUNTY ROAD 7593
JONESBORO AR
72401-7764
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-4744
  • Fax: 925-955-4744
Mailing address:
  • Phone: 870-932-4744
  • Fax: 925-955-4744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1870-C
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1870-C
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1870-C
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1870-C
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1870-C
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1870-C
License Number StateAR

VIII. Authorized Official

Name: ROBERT HEATH MEEKS
Title or Position: MEMBER
Credential: LCSW, NBCFCH, SAP
Phone: 870-932-4744