Provider Demographics
NPI:1801673405
Name:IMPACT COUNSELING CLINIC, INCORPORATED
Entity type:Organization
Organization Name:IMPACT COUNSELING CLINIC, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:870-285-1413
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:DIERKS
Mailing Address - State:AR
Mailing Address - Zip Code:71833-0416
Mailing Address - Country:US
Mailing Address - Phone:870-285-1413
Mailing Address - Fax:
Practice Address - Street 1:408 N 1ST ST STE C
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:AR
Practice Address - Zip Code:71943-9252
Practice Address - Country:US
Practice Address - Phone:870-356-7404
Practice Address - Fax:870-825-2060
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPACT COUNSELING CLINIC, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)