Healthcare Provider Details

I. General information

NPI: 1245084623
Provider Name (Legal Business Name): SOUTHLAND ELITE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 W SUNSET AVE STE D
SPRINGDALE AR
72762-4974
US

IV. Provider business mailing address

4021 W WALNUT ST STE 1115
ROGERS AR
72756-1842
US

V. Phone/Fax

Practice location:
  • Phone: 479-259-1090
  • Fax:
Mailing address:
  • Phone: 479-259-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALISA D MITCHELL
Title or Position: OWNER/CEO
Credential: LPC-S
Phone: 479-259-1090