1033355870 NPI number — MRS. AMANDA MARIE CRISP LPC, CCTP

Table of content: MRS. AMANDA MARIE CRISP LPC, CCTP (NPI 1033355870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033355870 NPI number — MRS. AMANDA MARIE CRISP LPC, CCTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISP
Provider First Name:
AMANDA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, CCTP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033355870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 N. WALTON BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-271-6203
Provider Business Mailing Address Fax Number:
479-271-6247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 JEFFERSON ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71701-3945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-836-8888
Provider Business Practice Location Address Fax Number:
870-836-8881
Provider Enumeration Date:
12/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  P1112098 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NONE . This is a "MENTAL HEALTH PROFESSIONAL-COUNSELOR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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