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General NPI Number Information
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NPI Number | 1669145694
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Entity Type | Organization
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Legal Business Name | PINK ELEPHANT THERAPY
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Dates
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Enumeration Date | 07/27/2021
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Last Update Date | 11/24/2021
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Provider Practice Location Address
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Address Line | 203 W MAIN ST STE K
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City | EL DORADO
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State | AR
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Zip | 71730-5604
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Country | US
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Telephone | 870-866-4653
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Fax |
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Provider Business Mailing Address
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Address Line | 203 W. MAIN ST. SUITE K
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City | EL DORADO
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State | AR
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Zip | 71730
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Country | US
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Telephone | 870-866-4653
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CONNIE DELORA TAUTE
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Credential | LPC, AADC, LADAC
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Telephone | 870-866-4653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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