Healthcare Provider Details

I. General information

NPI: 1265162937
Provider Name (Legal Business Name): KELLY POGUE STEPHENS LAMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 MAIN ST
VILONIA AR
72173-8072
US

IV. Provider business mailing address

50 VILANCO CUTOFF
VILONIA AR
72173-9876
US

V. Phone/Fax

Practice location:
  • Phone: 501-772-9278
  • Fax:
Mailing address:
  • Phone: 501-514-7854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2401020
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: