=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437471299
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNNIE DANIEL EZELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2010
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W WALNUT ST SUITE 1500
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72756-3521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-636-0083
-----------------------------------------------------
Fax | 479-636-0144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 MILLS DR
-----------------------------------------------------
City | BELLA VISTA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72714-6333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-4004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2021010667
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | P8611021
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------