=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881197697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NWA CHRISTIAN COUNSELING GROUP, INC. DBA BROOKWAY COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2018
-----------------------------------------------------
Last Update Date | 05/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 CARLTON ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-255-5414
-----------------------------------------------------
Fax | 855-277-8988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 CARLTON ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-3783
-----------------------------------------------------
Fax | 855-277-8988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AM
-----------------------------------------------------
Name | ANDREA NEULS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-571-0867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 1258-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1258-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------