Healthcare Provider Details

I. General information

NPI: 1548307853
Provider Name (Legal Business Name): KATHY GIPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 S OSWEGO AVE
RUSSELLVILLE AR
72802-2673
US

IV. Provider business mailing address

PO BOX 679
MORRILTON AR
72110-0679
US

V. Phone/Fax

Practice location:
  • Phone: 479-967-3370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number93-16E
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: