Provider Demographics
NPI:1740780634
Name:RAY, ALECIA NICOLE (BS)
Entity Type:Individual
Prefix:
First Name:ALECIA
Middle Name:NICOLE
Last Name:RAY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4576
Mailing Address - Country:US
Mailing Address - Phone:479-464-1060
Mailing Address - Fax:479-271-6307
Practice Address - Street 1:411 LENTZ RD
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-3740
Practice Address - Country:US
Practice Address - Phone:501-354-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR222Q00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor