=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700654779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECTED COUNSELING NWA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2023
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 NE MCCLAIN RD BLDG 7
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-3875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-439-9470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1202 NE MCCLAIN RD BLDG 7
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-3875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-439-9470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARISA GILBRETH
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 479-439-9470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------