Healthcare Provider Details

I. General information

NPI: 1881217222
Provider Name (Legal Business Name): ELIZABETH MATTOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIBBY THOMPSON

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 02/05/2022
Certification Date: 02/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 ALDERSGATE RD
LITTLE ROCK AR
72205-6606
US

IV. Provider business mailing address

560 SYLVAN AVENUE SUITE 1110
ENGLEWOOD CLIFFS NJ
07632-3171
US

V. Phone/Fax

Practice location:
  • Phone: 501-860-2120
  • Fax:
Mailing address:
  • Phone: 646-873-6600
  • Fax: 646-859-4440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-57077
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: