Basic Information
| Provider Information | |||||||||
| NPI: | 1205118049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUVALL | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | YVONNE | ||||||||
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| Credential: | M.ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727626683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797504843 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 E POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728304428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797548610 | ||||||||
| FaxNumber: | 4797548788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2011 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1503016 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | P1503016 | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 227034719 | 05 | AR | MEDICAID |