Provider Demographics
NPI:1376731539
Name:QUALLS, THERESA L
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:L
Last Name:QUALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N CEDAR ST
Mailing Address - Street 2:APT 1B
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3924
Mailing Address - Country:US
Mailing Address - Phone:501-410-7922
Mailing Address - Fax:
Practice Address - Street 1:4 SHACKLEFORD PLZ
Practice Address - Street 2:SUITE 204
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1826
Practice Address - Country:US
Practice Address - Phone:501-410-7922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1204052101YP2500X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200023740Medicaid