Provider Demographics
NPI:1033293733
Name:FAMILY PSYCHOLOGICAL CENTER
Entity Type:Organization
Organization Name:FAMILY PSYCHOLOGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:870-743-6225
Mailing Address - Street 1:623 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-3617
Mailing Address - Country:US
Mailing Address - Phone:870-743-6225
Mailing Address - Fax:870-743-6006
Practice Address - Street 1:623 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3617
Practice Address - Country:US
Practice Address - Phone:870-743-6225
Practice Address - Fax:870-743-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR00-12P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148984744Medicaid
AR5C757OtherBC/BS PROVIDER #
AR5C757Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #