Provider Demographics
NPI:1710935218
Name:EKDAHL, MARY MOORE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MOORE
Last Name:EKDAHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4004 MCCAIN BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8057
Mailing Address - Country:US
Mailing Address - Phone:501-812-4268
Mailing Address - Fax:501-812-4286
Practice Address - Street 1:4004 MCCAIN BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8057
Practice Address - Country:US
Practice Address - Phone:501-812-4268
Practice Address - Fax:501-812-4286
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR964P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139320719Medicaid
AR139320719Medicaid