Provider Demographics
NPI:1871039883
Name:SYSTEMIC FAMILY THERAPY LLC
Entity Type:Organization
Organization Name:SYSTEMIC FAMILY THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:RUGGIERO
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:501-400-6570
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-0897
Mailing Address - Country:US
Mailing Address - Phone:501-400-6570
Mailing Address - Fax:
Practice Address - Street 1:17724 I 30 STE 2 OFC 5
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2907
Practice Address - Country:US
Practice Address - Phone:501-400-6570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPO807061305R00000X
ARMO704002305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1699966697OtherNPI