Basic Information
| Provider Information | |||||||||
| NPI: | 1003225301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EZELL | ||||||||
| FirstName: | BRENTON | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EZELL | ||||||||
| OtherFirstName: | BRENT | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1815 PLEASANT GROVE RD. | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724057870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709336886 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 S 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | PIGGOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724542634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705980306 | ||||||||
| FaxNumber: | 8705980328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AR | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 11164-M | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 203630795 | 05 | AR | MEDICAID |