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615 N 19th St Fort Smith AR 72901-3319 | |
| (479) 785-4083 | |
| (479) 668-2059 |
| Full Name | |
|---|---|
| Speciality | Substance Abuse Rehabilitation Facility |
| Location | 615 N 19th St, Fort Smith, Arkansas |
| Authorized Official Name and Position | Ranee Lewis (OFFICE MANAGER) |
| Authorized Official Contact | 4797854083 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 4207 Fort Smith AR 72914-4207 Ph: (479) 785-4083 | 615 N 19th St Fort Smith AR 72901-3319 Ph: (479) 785-4083 |
| NPI Number | 1922166123 |
|---|---|
| Provider Enumeration Date | 12/04/2006 |
| Last Update Date | 09/27/2023 |
| Certification Date | 09/27/2023 |
| Medicare PECOS PAC ID | 9032433222 |
|---|---|
| Medicare Enrollment ID | O20150116001073 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922166123 | NPI | - | NPPES |
| 236252526 | Medicaid | AR | |
| 239197526 | Medicaid | AR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
| 324500000X | Substance Abuse Rehabilitation Facility | (* (Not Available)) | Primary |
| Provider Name | Angela Campagna |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1568949899 PECOS PAC ID: 1759620636 Enrollment ID: I20190312001263 |
| Provider Name | Kaitlyn Victoria Smith |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1053912360 PECOS PAC ID: 3375997349 Enrollment ID: I20230925001931 |
| Provider Name | David R Harris |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1851877849 PECOS PAC ID: 8325498454 Enrollment ID: I20240524002352 |
| Provider Name | James C Harris |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1548627565 PECOS PAC ID: 3476091125 Enrollment ID: I20240813003740 |
| Provider Name | Mandy Tigert |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1215079546 PECOS PAC ID: 0941733828 Enrollment ID: I20241030003338 |
| Provider Name | Casey Myers |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1366709347 PECOS PAC ID: 1951836006 Enrollment ID: I20241126001425 |
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