MEDICARE: FAYETTEVILLE PSYCHOTHERAPY ASSOCIATES, PLC

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	99-10P	AR

General Provider Information

NPI Number	:	1801807243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE PSYCHOTHERAPY ASSOCIATES, PLC

Provider Business Mailing Address
First Line	:	225 N EAST AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-5226
Country	:	US
Telephone Number	:	479-442-8900
Fax Number	:	479-442-8901

Provider Business Practice Location Address
First Line	:	225 N EAST AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-5226
Country	:	US
Telephone Number	:	479-442-8900
Fax Number	:	479-442-8901

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. WILLIAM EDWARD SPAINE
Credential	:	PSY.D.
Telephone Number	:	479-442-8900

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/22/2020

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