Healthcare Provider Details

I. General information

NPI: 1225134919
Provider Name (Legal Business Name): DALE CORDES PROVOST PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DALE S. CORDES PH.D.

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W 7TH ST 116T/LR
LITTLE ROCK AR
72205-5446
US

IV. Provider business mailing address

17 SUMMERLAND CT
LITTLE ROCK AR
72227-3846
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-6598
  • Fax: 501-257-6602
Mailing address:
  • Phone: 501-225-5037
  • Fax: 501-257-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number84-11P
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number84-11P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: