Provider Demographics
NPI:1609863562
Name:BEARE, DAVID J (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:BEARE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402330
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2330
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 240
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-709-7455
Practice Address - Fax:479-709-7456
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR021P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100838330AMedicaid
AR145577019Medicaid
OK100838330AMedicaid
AR145577019Medicaid