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General NPI Number Information
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NPI Number | 1255697330
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Entity Type | Organization
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Legal Business Name | CONWAY PSYCHOLOGICAL ASSESSMENT CENTER
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 04/03/2012
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Provider Practice Location Address
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Address Line | 1210 HOGAN LN SUITE 200
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City | CONWAY
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State | AR
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Zip | 72034-8001
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Country | US
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Telephone | 501-932-0255
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Fax | 501-932-0258
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Provider Business Mailing Address
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Address Line | 1210 HOGAN LN SUITE 200
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City | CONWAY
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State | AR
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Zip | 72034-8001
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Country | US
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Telephone | 501-932-0255
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Fax | 501-932-0258
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. KIM DIELMANN
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Credential | PH.D.
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Telephone | 501-932-0255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 07-27P
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License Number State | AR
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