Provider Demographics
NPI:1578870663
Name:COUNSELING CLINIC, INC.
Entity Type:Organization
Organization Name:COUNSELING CLINIC, INC.
Other - Org Name:SMALL GROUP THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:501-315-4224
Mailing Address - Street 1:110 PEARSON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4436
Mailing Address - Country:US
Mailing Address - Phone:501-315-4224
Mailing Address - Fax:501-778-0450
Practice Address - Street 1:310 WHITTINGTON AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-3406
Practice Address - Country:US
Practice Address - Phone:501-623-3477
Practice Address - Fax:501-624-7498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCERTIFIED (NO NUMBER251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182550526Medicaid
AR56879Medicare PIN