Provider Demographics
NPI:1043774516
Name:NWA PREMIER THERAPY
Entity Type:Organization
Organization Name:NWA PREMIER THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:479-372-7446
Mailing Address - Street 1:5305 W VILLAGE PKWY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758
Mailing Address - Country:US
Mailing Address - Phone:479-372-7446
Mailing Address - Fax:
Practice Address - Street 1:5305 W VILLAGE PKWY
Practice Address - Street 2:SUITE 8
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758
Practice Address - Country:US
Practice Address - Phone:479-372-7446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP0304018Medicaid