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General NPI Number Information
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NPI Number | 1861925968
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Entity Type | Organization
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Legal Business Name | LIFE TREK, LLC
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Dates
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Enumeration Date | 04/05/2017
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Last Update Date | 04/05/2017
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Provider Practice Location Address
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Address Line | 21 SYCAMORE ST
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City | CABOT
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State | AR
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Zip | 72023-3714
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Country | US
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Telephone | 501-617-5678
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Fax |
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Provider Business Mailing Address
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Address Line | 21 SYCAMORE ST
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City | CABOT
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State | AR
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Zip | 72023-3714
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Country | US
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Telephone | 501-617-5678
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. CATHY LYNN STATON
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Credential | PH.D., L.P.
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Telephone | 501-617-5678
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 17-04P
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License Number State | AR
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