Basic Information
| Provider Information | |||||||||
| NPI: | 1558390997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | VERONICA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6430 | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727666430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4795245197 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 S HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | SILOAM SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727613304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4795245197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 91-2E | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 5Y342 | 01 | AR | BLUE SHIELD PROVIDER # | OTHER |