Provider Demographics
NPI:1922395870
Name:WYSOCKI, ASHLEY DONALDSON (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DONALDSON
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:DONALDSON
Other - Last Name:WITHROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1101 MORGAN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3949
Practice Address - Country:US
Practice Address - Phone:870-335-9483
Practice Address - Fax:870-335-9487
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6439-C1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183586795Medicaid
AR5MM24OtherBCBS
AR409446YJUJMedicare PIN