Provider Demographics
NPI:1821659491
Name:FAYETTE-KIDS COUNSELING, LLC
Entity Type:Organization
Organization Name:FAYETTE-KIDS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLYE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:479-502-4943
Mailing Address - Street 1:1395 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3060
Mailing Address - Country:US
Mailing Address - Phone:479-502-4943
Mailing Address - Fax:
Practice Address - Street 1:112 E SUNBRIDGE DR STE 7
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2860
Practice Address - Country:US
Practice Address - Phone:479-502-4943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1871832196OtherNPI