Provider Demographics
NPI:1518689801
Name:WHITEIS, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:WHITEIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4309 ELM ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-9013
Mailing Address - Country:US
Mailing Address - Phone:479-651-6116
Mailing Address - Fax:
Practice Address - Street 1:3111 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-785-9495
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12421-M104100000X
171M00000X
AR1241-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator