Provider Demographics
NPI:1255605572
Name:CLINICAL PSYCHOLOGY FOR HEALTH AND PERFORMANCE PA
Entity type:Organization
Organization Name:CLINICAL PSYCHOLOGY FOR HEALTH AND PERFORMANCE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANITRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:479-667-1217
Mailing Address - Street 1:11347 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-9676
Mailing Address - Country:US
Mailing Address - Phone:479-667-1217
Mailing Address - Fax:
Practice Address - Street 1:3401 ROGERS AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2986
Practice Address - Country:US
Practice Address - Phone:479-242-4560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR82-01P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty