=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336675073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINDSEY GIPSON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2017
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1160 MUSKET ST
-----------------------------------------------------
City | PRAIRIE GROVE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72753-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-806-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 E CENTER ST SUITE 320 C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-806-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | MRS. LINDSEY GIPSON
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 479-806-2053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | P1609142
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------