Healthcare Provider Details

I. General information

NPI: 1750878203
Provider Name (Legal Business Name): FOUNDATION: A WELLNESS PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W WASHINGTON AVE
JONESBORO AR
72401
US

IV. Provider business mailing address

533 W WASHINGTON AVE
JONESBORO AR
72401-2782
US

V. Phone/Fax

Practice location:
  • Phone: 870-229-0302
  • Fax: 870-520-6482
Mailing address:
  • Phone: 870-229-0302
  • Fax: 870-520-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICKI LANELL WHITE
Title or Position: OWNER
Credential: LCSW
Phone: 573-344-0976