Basic Information
| Provider Information | |||||||||
| NPI: | 1417108846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNSELING SERVICES OF EASTERN ARKANSAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709724939 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 BROADMOOR DR | ||||||||
| Address2: | |||||||||
| City: | BRINKLEY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720212057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707343202 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | LYERLY | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8709724939 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNSELING SERVICES OF EASTERN ARKANSAS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 172036526 | 05 | AR | MEDICAID |