Provider Demographics
NPI:1609464775
Name:IDENTITY BEHAVIOR HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:IDENTITY BEHAVIOR HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:870-267-2200
Mailing Address - Street 1:2401 SHERATON PARK DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6869
Mailing Address - Country:US
Mailing Address - Phone:870-267-2200
Mailing Address - Fax:
Practice Address - Street 1:2401 SHERATON PARK DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6869
Practice Address - Country:US
Practice Address - Phone:870-267-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health