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General NPI Number Information
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NPI Number | 1598864043
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Entity Type | Organization
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Legal Business Name | NW ARKANSAS PSYCHOLOGICAL GROUP INC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 1706 E JOYCE BLVD SUITE 3
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5238
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Country | US
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Telephone | 479-442-9381
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Fax | 479-442-9396
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Provider Business Mailing Address
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Address Line | 1706 E JOYCE BLVD SUITE 3
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City | FAYETTEVILLE
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State | AR
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Zip | 72703
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Country | US
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Telephone | 479-442-9381
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Fax | 479-442-9396
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DIANE P BACK
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Credential | R.N.
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Telephone | 479-442-9381
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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 | 78-18 P
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License Number State | AR
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