Basic Information
| Provider Information | |||||||||
| NPI: | 1710136452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROMWELL | ||||||||
| FirstName: | JUANNA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 DONS WAY | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016247111 | ||||||||
| FaxNumber: | 5016205109 | ||||||||
| Practice Location | |||||||||
| Address1: | 3399 FINCH RD | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719297541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018653363 | ||||||||
| FaxNumber: | 5018653362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2008 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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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 | 101Y00000X | A0707055 | AR | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 116399726 | 05 | AR | MEDICAID |