Basic Information
| Provider Information | |||||||||
| NPI: | 1265834733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIZZIAR | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRATZ | ||||||||
| OtherFirstName: | HALEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 S ROSE ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721502451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709172171 | ||||||||
| FaxNumber: | 8709172161 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S ROSE ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721502451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709172171 | ||||||||
| FaxNumber: | 8709172161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A1902015 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.