Healthcare Provider Details

I. General information

NPI: 1578929626
Provider Name (Legal Business Name): KENNETH CARSWELL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 WHITEAKER RD
PINE BLUFF AR
71603-8076
US

IV. Provider business mailing address

6120 WHITEAKER RD
PINE BLUFF AR
71603-8076
US

V. Phone/Fax

Practice location:
  • Phone: 870-718-6007
  • Fax:
Mailing address:
  • Phone: 870-718-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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 Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberIMH 13452
License Number StateFL

VIII. Authorized Official

Name: MR. KENNETH CARSWELL
Title or Position: CEO
Credential: MS, BCPC, PTSDC, CDC
Phone: 870-718-6007