Provider Demographics
NPI:1205056298
Name:SONNTAG, MARY JANE (PSYD PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:SONNTAG
Suffix:
Gender:F
Credentials:PSYD PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6122
Mailing Address - Country:US
Mailing Address - Phone:479-270-3302
Mailing Address - Fax:479-845-3946
Practice Address - Street 1:1116 S WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6122
Practice Address - Country:US
Practice Address - Phone:479-270-3302
Practice Address - Fax:479-845-3946
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR892P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S979OtherBCBS
AR5S979OtherBCBS