Basic Information
Provider Information
NPI: 1003142407
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STONE
FirstName: COLLEEN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MHPP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 20400 COL GLENN RD
Address2:  
City: LITTLE ROCK
State: AR
PostalCode: 722105323
CountryCode: US
TelephoneNumber: 5018215500
FaxNumber:  
Practice Location
Address1: 20400 COL GLENN RD
Address2:  
City: LITTLE ROCK
State: AR
PostalCode: 722105323
CountryCode: US
TelephoneNumber: 5018215500
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/20/2009
LastUpdateDate: 10/20/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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