Provider Demographics
NPI:1114100328
Name:GONNER, GRACIE ANN (MS)
Entity Type:Individual
Prefix:MS
First Name:GRACIE
Middle Name:ANN
Last Name:GONNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S TENTH
Mailing Address - Street 2:
Mailing Address - City:WEST HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72390-3135
Mailing Address - Country:US
Mailing Address - Phone:870-572-6132
Mailing Address - Fax:870-338-8048
Practice Address - Street 1:406 PECAN ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-3212
Practice Address - Country:US
Practice Address - Phone:870-338-8447
Practice Address - Fax:870-338-8048
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR80-24E103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling