Provider Demographics
NPI:1578184982
Name:CAPPS, CHARLEY MARISSA
Entity Type:Individual
Prefix:
First Name:CHARLEY
Middle Name:MARISSA
Last Name:CAPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLEY
Other - Middle Name:MARISSA
Other - Last Name:GALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:
Practice Address - Street 1:212 S LINCOLN ST STE A
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9722
Practice Address - Country:US
Practice Address - Phone:479-770-0744
Practice Address - Fax:479-770-0176
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR274145706Medicaid