Provider Demographics
NPI:1003225301
Name:EZELL, BRENTON PAUL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRENTON
Middle Name:PAUL
Last Name:EZELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:
Other - Last Name:EZELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-336-1339
Practice Address - Street 1:111 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:PIGGOTT
Practice Address - State:AR
Practice Address - Zip Code:72454-2634
Practice Address - Country:US
Practice Address - Phone:870-598-0306
Practice Address - Fax:870-598-0328
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 1041C0700X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203630795Medicaid