Provider Demographics
NPI:1205118049
Name:DUVALL, STACI YVONNE (MED, LPC)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:YVONNE
Last Name:DUVALL
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-4843
Practice Address - Street 1:1021 E POPLAR ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4428
Practice Address - Country:US
Practice Address - Phone:479-754-8610
Practice Address - Fax:479-754-8788
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1503016101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227034719Medicaid