Healthcare Provider Details

I. General information

NPI: 1598996076
Provider Name (Legal Business Name): TAKING CHARGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2009
Last Update Date: 08/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 S STATE ST
PINE BLUFF AR
71601-5851
US

IV. Provider business mailing address

PO BOX 9802
PINE BLUFF AR
71611-9802
US

V. Phone/Fax

Practice location:
  • Phone: 870-540-7769
  • Fax: 870-247-1494
Mailing address:
  • Phone: 870-540-7769
  • Fax: 870-247-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. GENEVA CLARK
Title or Position: COORDINATOR
Credential: B.S. SOCIAL & BEHAVI
Phone: 870-540-7769