Healthcare Provider Details

I. General information

NPI: 1083462980
Provider Name (Legal Business Name): ODYSSEY THERAPY NWA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 W VILLAGE PKWY STE 4
ROGERS AR
72758-8201
US

IV. Provider business mailing address

4207 NE BLUE SPRUCE AVE
BENTONVILLE AR
72712-4935
US

V. Phone/Fax

Practice location:
  • Phone: 479-222-0688
  • Fax:
Mailing address:
  • Phone: 476-586-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LINDSEY HART
Title or Position: OWNER
Credential: MS, LAC
Phone: 479-222-0688