Provider Demographics
NPI:1225134919
Name:PROVOST, DALE CORDES (PHD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:CORDES
Last Name:PROVOST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DALE
Other - Middle Name:S
Other - Last Name:CORDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:17 SUMMERLAND CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-3846
Mailing Address - Country:US
Mailing Address - Phone:501-225-5037
Mailing Address - Fax:501-257-6602
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:116T/LR
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-6598
Practice Address - Fax:501-257-6602
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR84-11P103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist