Basic Information
| Provider Information | |||||||||
| NPI: | 1093192338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THRASHER | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MHPP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VILONIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017729278 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1805053 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | AR | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | P2012114 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.