Provider Demographics
NPI:1649501461
Name:WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.-31ST STREET CLINIC
Entity type:Organization
Organization Name:WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.-31ST STREET CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:479-452-6650
Mailing Address - Street 1:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-785-9495
Practice Address - Street 1:2100 N 31ST ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-6140
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-785-9495
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-18
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181576526Medicaid
56701Medicare PIN