Basic Information
| Provider Information | |||||||||
| NPI: | 1114063765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | CLARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 E MAIN ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | BATESVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725014660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705694890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | A1608108 | AR | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | AR | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | P1810134 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.