Provider Demographics
NPI:1205113222
Name:WOOLVERTON INSTITUTE FOR PSYCHOTHERAPY
Entity type:Organization
Organization Name:WOOLVERTON INSTITUTE FOR PSYCHOTHERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOLVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:479-442-4080
Mailing Address - Street 1:21 W MOUNTAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-6086
Mailing Address - Country:US
Mailing Address - Phone:479-442-4080
Mailing Address - Fax:212-253-4136
Practice Address - Street 1:21 W MOUNTAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6086
Practice Address - Country:US
Practice Address - Phone:479-442-4080
Practice Address - Fax:212-253-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04-19P251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management