Provider Demographics
NPI:1710535935
Name:FAYETTEVILLE PSYCHIATRY, LTD
Entity Type:Organization
Organization Name:FAYETTEVILLE PSYCHIATRY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-966-6993
Mailing Address - Street 1:4641 E BRIDGEWATER LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4670
Mailing Address - Country:US
Mailing Address - Phone:479-966-6993
Mailing Address - Fax:
Practice Address - Street 1:205 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-4238
Practice Address - Country:US
Practice Address - Phone:479-966-6993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty