Healthcare Provider Details

I. General information

NPI: 1306629258
Provider Name (Legal Business Name): ELLEN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 JOHNSON MILL BLVD STE 103
SPRINGDALE AR
72762-6412
US

IV. Provider business mailing address

PO BOX 9541
FAYETTEVILLE AR
72703-0026
US

V. Phone/Fax

Practice location:
  • Phone: 479-435-4207
  • Fax: 479-935-3180
Mailing address:
  • Phone: 479-435-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: