Provider Demographics
NPI:1740477322
Name:DEBOSE, ILA MAUREEN (LCSW)
Entity type:Individual
Prefix:
First Name:ILA
Middle Name:MAUREEN
Last Name:DEBOSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 FREE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2522
Mailing Address - Country:US
Mailing Address - Phone:479-719-7051
Mailing Address - Fax:479-494-5685
Practice Address - Street 1:4943 OLD GREENWOOD RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6923
Practice Address - Country:US
Practice Address - Phone:479-719-7051
Practice Address - Fax:479-242-2653
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2158-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical