Healthcare Provider Details

I. General information

NPI: 1578775466
Provider Name (Legal Business Name): ADOLESCENT AND FAMILY ADVOCATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 ALMA HIGHWAY
VAN BUREN AR
72956
US

IV. Provider business mailing address

3103 ALMA HIGHWAY
VAN BUREN AR
72956
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-4483
  • Fax: 479-262-5041
Mailing address:
  • Phone: 479-474-4483
  • Fax: 479-262-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberARKANSAS P0401005
License Number StateAR

VIII. Authorized Official

Name: MRS. MELISSA ROBERTSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 479-474-4483