1154296630 NPI number — ST BERNARDS PHYSICIAN CLINICS, INC.

Table of content: KINDRA RENEE MARIETTI LPC, NCC (NPI 1003560483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154296630 NPI number — ST BERNARDS PHYSICIAN CLINICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST BERNARDS PHYSICIAN CLINICS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1154296630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1331
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72403-1331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-336-7410
Provider Business Mailing Address Fax Number:
870-336-5677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 S CHURCH ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-4176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-336-7410
Provider Business Practice Location Address Fax Number:
870-336-5677
Provider Enumeration Date:
10/06/2025

Additional Information

Authorized Official

Authorized Official Last Name:
LIEBLONG
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-932-7024

Provider Taxonomy Codes

  • Taxonomy code: 2086S0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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