MEDICARE: DR. ANITRA S FAY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	821P	AR

General Provider Information

NPI Number	:	1649224080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANITRA S FAY PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 3487
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72913-3487
Country	:	US
Telephone Number	:	479-783-0445
Fax Number	:	479-782-5883

Provider Business Practice Location Address
First Line	:	3801 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3045
Country	:	US
Telephone Number	:	479-783-0445
Fax Number	:	479-782-5883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/08/2007

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