=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639180482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KATHLEEN ANN MARKS-HENDERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5111 ROGERS AVE SUITE 525
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-461-3281
-----------------------------------------------------
Fax | 479-478-0282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3023 MOSS RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-6889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-461-3281
-----------------------------------------------------
Fax | 479-478-0282
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | P0303004
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------