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General NPI Number Information
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NPI Number | 1194106476
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGY CENTER OF RUSSELLVILLE, LLC
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Dates
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Enumeration Date | 06/12/2015
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Last Update Date | 06/12/2015
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Provider Practice Location Address
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Address Line | 2621 W MAIN ST SUITE 7
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2534
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Country | US
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Telephone | 479-219-5041
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Fax | 479-219-5046
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Provider Business Mailing Address
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Address Line | 2621 W MAIN ST SUITE 7
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-2534
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Country | US
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Telephone | 479-219-5041
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Fax | 479-219-5046
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHRISTINA LIN COUCH
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Credential | PSYD
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Telephone | 479-219-5041
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 12-01P
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License Number State | AR
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