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General NPI Number Information
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NPI Number | 1982361671
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Entity Type | Organization
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Legal Business Name | REFUGE AND RESTORE PLLC
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Dates
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Enumeration Date | 11/17/2021
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Last Update Date | 01/29/2022
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Provider Practice Location Address
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Address Line | 4943 OLD GREENWOOD RD STE 9
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City | FORT SMITH
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State | AR
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Zip | 72903-6923
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Country | US
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Telephone | 479-353-0016
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Fax |
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Provider Business Mailing Address
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Address Line | 2908 RIVERBEND DR
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City | FORT SMITH
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State | AR
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Zip | 72903-5325
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Country | US
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Telephone | 379-353-0016
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL, SOLE OWNER
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Name | DEANNA VITALE
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Credential | LCSW
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Telephone | 479-353-0016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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