Provider Demographics
NPI:1649419607
Name:CHRISTIAN PSYCHOLOGICAL RESOURCES
Entity Type:Organization
Organization Name:CHRISTIAN PSYCHOLOGICAL RESOURCES
Other - Org Name:CPR
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE-PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:479-967-3700
Mailing Address - Street 1:PO BOX 9070
Mailing Address - Street 2:2621 WEST MAIN STREET, SUITE 4
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9070
Mailing Address - Country:US
Mailing Address - Phone:479-967-3700
Mailing Address - Fax:479-967-3323
Practice Address - Street 1:2621 W MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2551
Practice Address - Country:US
Practice Address - Phone:479-967-3700
Practice Address - Fax:479-967-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR88-06P261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56523Medicare PIN