Healthcare Provider Details

I. General information

NPI: 1780638742
Provider Name (Legal Business Name): RETHA WOODS GREGORY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

IV. Provider business mailing address

PO BOX 6430
SPRINGDALE AR
72766-6430
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-751-4346
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-751-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP8812026
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: