=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124151220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASCENT ACQUISITIONS CORP-PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 04/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 BYRUM RD
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-8033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-532-2600
-----------------------------------------------------
Fax | 870-532-9484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3012 TURMAN DR
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72404-8998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-819-0200
-----------------------------------------------------
Fax | 870-819-0217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SPECIALIST
-----------------------------------------------------
Name | HOLLY ALLGOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-819-0232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------