Healthcare Provider Details

I. General information

NPI: 1770405334
Provider Name (Legal Business Name): CHARLIE WINFREY BEHAVIORAL TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20400 COLONEL GLENN RD
LITTLE ROCK MO
72002
US

IV. Provider business mailing address

20400 COLONEL GLENN RD
LITTLE ROCK MO
72002
US

V. Phone/Fax

Practice location:
  • Phone: 501-821-5500
  • Fax: 501-954-7470
Mailing address:
  • Phone: 501-821-5500
  • Fax: 501-954-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: