Basic Information
| Provider Information | |||||||||
| NPI: | 1205980497 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASCENT ACQUISITIONS CORP-CYPDC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CHILD & YOUTH DEVELOPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 TURMAN DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724048998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708190200 | ||||||||
| FaxNumber: | 8708190217 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S CHURCH ST | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724014176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709359911 | ||||||||
| FaxNumber: | 8709353450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | ALLGOOD | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | INS BILLING REP | ||||||||
| AuthorizedOfficialTelephone: | 8708190232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 160785526 | 05 | AR | MEDICAID | 160746742 | 05 | AR | MEDICAID | 57885 | 01 | AR | ARKANSAS BCBS | OTHER |