Healthcare Provider Details

I. General information

NPI: 1437471299
Provider Name (Legal Business Name): JOHNNIE DANIEL EZELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W WALNUT ST SUITE 1500
ROGERS AR
72756-3521
US

IV. Provider business mailing address

24 MILLS DR
BELLA VISTA AR
72714-6333
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-0083
  • Fax: 479-636-0144
Mailing address:
  • Phone: 479-466-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021010667
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP8611021
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: