Provider Demographics
NPI:1205388071
Name:IMPACT COUNSELING CLINIC, INCORPORATED
Entity Type:Organization
Organization Name:IMPACT COUNSELING CLINIC, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:870-285-1413
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:DIERKS
Mailing Address - State:AR
Mailing Address - Zip Code:71833-0575
Mailing Address - Country:US
Mailing Address - Phone:870-285-1413
Mailing Address - Fax:870-825-2060
Practice Address - Street 1:1124 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DIERKS
Practice Address - State:AR
Practice Address - Zip Code:71833-9421
Practice Address - Country:US
Practice Address - Phone:870-285-1413
Practice Address - Fax:870-825-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health