Healthcare Provider Details

I. General information

NPI: 1457723686
Provider Name (Legal Business Name): HPT EDGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S RAINBOW RD
ROGERS AR
72758-8821
US

IV. Provider business mailing address

1601 S RAINBOW RD
ROGERS AR
72758-8821
US

V. Phone/Fax

Practice location:
  • Phone: 479-310-6382
  • Fax: 479-254-1099
Mailing address:
  • Phone: 479-310-6382
  • Fax: 479-254-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1505039
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number101YP2500X
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM1501003
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2013015040
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC44465
License Number StateCA

VIII. Authorized Official

Name: MR. JAMES RICHARD VICCARO
Title or Position: PRESIDENT
Credential: LPC, LMFT
Phone: 479-310-6382