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General NPI Number Information
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NPI Number | 1942895388
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Entity Type | Individual
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Provider Name | GARY D MCDOUGAL II CADC, PRPS
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Gender | Male
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Dates
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Enumeration Date | 03/08/2021
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Last Update Date | 03/08/2021
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Provider Practice Location Address
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Address Line | 614 N MARTIN ST
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City | WARREN
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State | AR
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Zip | 71671-1904
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Country | US
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Telephone | 870-489-7903
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Fax |
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Provider Business Mailing Address
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Address Line | GARY MCDOUGAL 5029 ALEXANDER RD.
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City | PINE BLUFF
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State | AR
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Zip | 71603
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Country | US
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Telephone | 870-489-7903
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 034
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1690
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License Number State | AR
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