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General NPI Number Information
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NPI Number | 1871039883
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Entity Type | Organization
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Legal Business Name | SYSTEMIC FAMILY THERAPY LLC
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Dates
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Enumeration Date | 01/13/2017
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 17724 I 30 STE 2 OFC 5
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City | BENTON
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State | AR
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Zip | 72019-2907
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Country | US
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Telephone | 501-400-6570
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 897
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City | BENTON
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State | AR
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Zip | 72018-0897
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Country | US
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Telephone | 501-400-6570
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | DR. ELIZABETH RUGGIERO WALLIS
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Credential | PHD
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Telephone | 501-400-6570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | MO704002
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | PO807061
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License Number State | AR
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