Provider Demographics
NPI:1235167578
Name:VAN KIRK, DONNA M (EDD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:VAN KIRK
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 S KESTREL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1322
Mailing Address - Country:US
Mailing Address - Phone:479-466-0960
Mailing Address - Fax:479-431-4948
Practice Address - Street 1:204 N EAST AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5225
Practice Address - Country:US
Practice Address - Phone:479-466-9609
Practice Address - Fax:479-431-4948
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8210P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116603719Medicaid
AR710764588Medicare UPIN
AR116603719Medicaid