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General NPI Number Information
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NPI Number | 1831220334
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Entity Type | Organization
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Legal Business Name | PEDIATRIC SPECIALTY CARE
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2410 PINE ST
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City | ARKADELPHIA
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State | AR
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Zip | 71923-4335
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Country | US
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Telephone | 870-245-2210
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Fax |
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Provider Business Mailing Address
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Address Line | 141 GRISHAM RD
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City | ROYAL
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State | AR
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Zip | 71968-9563
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Country | US
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Telephone | 501-282-2750
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH PROFESSIONAL
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Name | MR. LARRY LAMAR GRANT
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Credential | LPC
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Telephone | 870-245-2210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | P0607039
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License Number State | AR
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