Provider Demographics
NPI:1548398910
Name:PSYCHOLOGICAL CARE CENTER
Entity Type:Organization
Organization Name:PSYCHOLOGICAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEROECK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:870-972-4770
Mailing Address - Street 1:308 W MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2741
Mailing Address - Country:US
Mailing Address - Phone:870-972-4770
Mailing Address - Fax:
Practice Address - Street 1:308 W MONROE AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2741
Practice Address - Country:US
Practice Address - Phone:870-972-4770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE3022OtherELECTRONIC SUBMITTER #
AR5C597Medicare UPIN