Provider Demographics
NPI:1649224080
Name:FAY, ANITRA S (PHD)
Entity type:Individual
Prefix:DR
First Name:ANITRA
Middle Name:S
Last Name:FAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3487
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3487
Mailing Address - Country:US
Mailing Address - Phone:479-783-0445
Mailing Address - Fax:479-782-5883
Practice Address - Street 1:3801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3045
Practice Address - Country:US
Practice Address - Phone:479-783-0445
Practice Address - Fax:479-782-5883
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR821P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56130Medicare ID - Type Unspecified