Healthcare Provider Details

I. General information

NPI: 1366806945
Provider Name (Legal Business Name): RESURGENT MHT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 S HORSEBARN RD
ROGERS AR
72758-8795
US

IV. Provider business mailing address

324 RAVENWOOD RD
SILOAM SPRINGS AR
72761-5550
US

V. Phone/Fax

Practice location:
  • Phone: 479-657-4636
  • Fax:
Mailing address:
  • Phone: 479-220-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberA003818
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberA003818
License Number StateAR

VIII. Authorized Official

Name: DONALD E WLEKLINSKI
Title or Position: OWNER
Credential: APRN
Phone: 479-220-2772