Provider Demographics
NPI:1235424326
Name:RIVER VALLEY PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:RIVER VALLEY PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:479-567-5654
Mailing Address - Street 1:P.O. BOX 10323
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72812
Mailing Address - Country:US
Mailing Address - Phone:479-567-5654
Mailing Address - Fax:479-567-5661
Practice Address - Street 1:3101 WEST 2ND CT
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-567-5654
Practice Address - Fax:479-567-5661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1611170101Y00000X
AR09-16P103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty