Provider Demographics
NPI:1821210386
Name:SMALL GROUP THERAPY, INC.
Entity Type:Organization
Organization Name:SMALL GROUP THERAPY, INC.
Other - Org Name:FAIRWEATHER MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-623-3477
Mailing Address - Street 1:311 WHITTINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-3407
Mailing Address - Country:US
Mailing Address - Phone:501-623-3477
Mailing Address - Fax:501-624-7498
Practice Address - Street 1:320 WHITTINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901
Practice Address - Country:US
Practice Address - Phone:501-623-3477
Practice Address - Fax:501-624-7498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0000320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130817732Medicaid