Basic Information
| Provider Information | |||||||||
| NPI: | 1871521476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REST | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6430 | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727666430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797501739 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S 48TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727626683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797502020 | ||||||||
| FaxNumber: | 4797508967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 31-94P | AR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5S864 | 01 | AR | BLUE SHIELD PROVIDER # | OTHER |