=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134742133
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM TODD INSTITUTE FOR FAMILY WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2020
-----------------------------------------------------
Last Update Date | 05/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1374 HIGHWAY 62 W
-----------------------------------------------------
City | POCAHONTAS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72455-3790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-743-2546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1374 HIGHWAY 62 W
-----------------------------------------------------
City | POCAHONTAS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72455-3790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-743-2546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | POLLY HARRIS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 870-810-1645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------