Provider Demographics
NPI:1073652400
Name:CANTRELL, EYDIE NERISSA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:EYDIE
Middle Name:NERISSA
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 COUNTY ROAD 458
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-8212
Mailing Address - Country:US
Mailing Address - Phone:870-425-5252
Mailing Address - Fax:
Practice Address - Street 1:18 COUNTY ROAD 458
Practice Address - Street 2:CHILD AND YOUTH PEDIATRIC DAY CLINIC
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-8212
Practice Address - Country:US
Practice Address - Phone:870-425-5252
Practice Address - Fax:870-425-5254
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0607043101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor