=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083913065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL DAWN ZEHM LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2011
-----------------------------------------------------
Last Update Date | 03/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 S PALM ARKANSAS STATE HOSPITAL
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-686-9407
-----------------------------------------------------
Fax | 501-686-9298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13600 OTTER CREEK PKWY APT 204
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72210-5714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-426-3951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 2345-M
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------