Provider Demographics
NPI:1588672638
Name:THE MENTAL FITNESS CENTER OF THE OZARKS,INC
Entity Type:Organization
Organization Name:THE MENTAL FITNESS CENTER OF THE OZARKS,INC
Other - Org Name:HARRIS AND ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:870-577-2830
Mailing Address - Street 1:128 SAINT ANDREWS CIR
Mailing Address - Street 2:
Mailing Address - City:HIDEAWAY
Mailing Address - State:TX
Mailing Address - Zip Code:75771-5056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 W SHERMAN AVE
Practice Address - Street 2:STE F
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2743
Practice Address - Country:US
Practice Address - Phone:870-577-2830
Practice Address - Fax:871-741-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR76 19P103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101734719Medicaid
AR56201OtherBLUE CROSS IDENTIFIER
AR56201OtherBLUE CROSS IDENTIFIER