Healthcare Provider Details

I. General information

NPI: 1841557840
Provider Name (Legal Business Name): DUSTIN GUDDE MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date: 08/09/2019
Reactivation Date: 08/21/2019

III. Provider practice location address

2400 S 48TH STREET
SPRINGDALE AR
72762
US

IV. Provider business mailing address

4960 SPRINGHOUSE DRIVE
SPRINGDALE AR
72762
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-750-8967
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-8967

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: