Provider Demographics
NPI:1720742398
Name:BLAND, KATIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BLAND
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:2414 S 57TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3855
Practice Address - Country:US
Practice Address - Phone:479-280-9980
Practice Address - Fax:501-421-2336
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12115-M104100000X
ARPLMSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR283635795Medicaid