Organization
SYSTEMIC FAMILY THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ELIZABETH RUGGIERO WALLIS PHD (THERAPIST)
(501) 400-6570
Entity
Organization
Contact information
Practice address
17724 I 30 STE 2 OFC 5, BENTON, AR 72019-2907
(501) 400-6570
Mailing address
PO BOX 897, BENTON, AR 72018-0897
(501) 400-6570
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
MO704002
AR
305R00000X
Preferred Provider Organization
Primary
PO807061
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1699966697
NPI
AR
Enumeration date
01/13/2017
Last updated
06/24/2019
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