Healthcare Provider Details

I. General information

NPI: 1013408137
Provider Name (Legal Business Name): MARA ELIZABETH WHITESIDE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARA ELIZABETH WOOD PHD

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 S. GENE GEORGE BLVD. STE. 100
SPRINGDALE AR
72762
US

IV. Provider business mailing address

2575 S. GENE GEORGE BLVD STE. 100
SPRINGDALE AR
72762
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-0125
  • Fax:
Mailing address:
  • Phone: 479-750-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number17-24P
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number17-24P
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number17-24P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: