1376008433 NPI number — PREVAIL COUNSELING SERVICES, LLC

Table of content: (NPI 1376008433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376008433 NPI number — PREVAIL COUNSELING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVAIL COUNSELING SERVICES, LLC
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:
1376008433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
706 CARTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72364-2403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-295-9422
Provider Business Mailing Address Fax Number:
855-765-7701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 MID CONTINENT PLZ STE 404
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MEMPHIS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72301-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-294-9522
Provider Business Practice Location Address Fax Number:
855-765-7701
Provider Enumeration Date:
02/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
INCORPORATOR
Authorized Official Telephone Number:
901-295-9422

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1811209745 . This is a "MENTAL HEALTH THERAPIST" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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