1073102620 NPI number — PROSPERING HOPE COUNSELING PLLC

Table of content: (NPI 1073102620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073102620 NPI number — PROSPERING HOPE COUNSELING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSPERING HOPE COUNSELING PLLC
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:
1073102620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72556-0245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-300-2112
Provider Business Mailing Address Fax Number:
844-377-1447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 SCHOOL DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72556-8620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-300-2112
Provider Business Practice Location Address Fax Number:
844-377-1447
Provider Enumeration Date:
01/18/2021

Additional Information

Authorized Official

Authorized Official Last Name:
INGRAM
Authorized Official First Name:
DANA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-300-2112

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 227890719 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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