Healthcare Provider Details

I. General information

NPI: 1194297648
Provider Name (Legal Business Name): JOHN M RAY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR 116B/NLR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

2200 FORT ROOTS DR 116B/NLR
NORTH LITTLE ROCK AR
72114-1709
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-2321
  • Fax:
Mailing address:
  • Phone: 501-257-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number18-24P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: