Healthcare Provider Details

I. General information

NPI: 1619161833
Provider Name (Legal Business Name): CONSOLIDATED YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 STADIUM BLVD
JONESBORO AR
72404-9384
US

IV. Provider business mailing address

4220 STADIUM BLVD
JONESBORO AR
72404-9384
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-1110
  • Fax: 870-972-5433
Mailing address:
  • Phone: 870-972-1110
  • Fax: 870-972-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10011
License Number StateAR

VIII. Authorized Official

Name: MS. BONNIE SUE SMITH
Title or Position: EXEC. DIRECTOR
Credential:
Phone: 870-972-1110