Provider Demographics
NPI:1598058489
Name:NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:MIDSOUTH HEALTH SYSTEMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-972-4939
Mailing Address - Street 1:2707 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7213
Mailing Address - Country:US
Mailing Address - Phone:870-972-4939
Mailing Address - Fax:870-972-4911
Practice Address - Street 1:905 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2001
Practice Address - Country:US
Practice Address - Phone:870-735-4511
Practice Address - Fax:870-735-5260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-25
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18417774Medicaid
5B9556Medicare PIN