Provider Demographics
NPI:1578181236
Name:BLACK BOX COUNSELING AND THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:BLACK BOX COUNSELING AND THERAPEUTIC SERVICES
Other - Org Name:BLAQK BOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHELLER
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LPC
Authorized Official - Phone:870-530-5739
Mailing Address - Street 1:912 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3852
Mailing Address - Country:US
Mailing Address - Phone:870-530-5739
Mailing Address - Fax:844-908-2206
Practice Address - Street 1:1000 S CARAWAY RD STE 103
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4465
Practice Address - Country:US
Practice Address - Phone:870-530-5739
Practice Address - Fax:844-908-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1922443993Medicaid