Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 80-24E | AR |
NPI | 1114100328 |
---|---|
Provider Name | Ms. Gracie Ann Gonner |
First Address | West Helena, AR 72390-3135 |
Second Address | Helena, AR 72342-3212 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2007 |
Last Update Date | 20/10/2008 |