NPIMap

Organization Active NPI

Systemic Family Therapy LLC

  • Preferred Provider Organization
  • Benton, AR
National Provider Identifier
1871039883
Registry record updated Jun 24, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Preferred Provider OrganizationTaxonomy code 305R00000X
License
PO807061 Issued in AR
Legal business name
SYSTEMIC FAMILY THERAPY LLC
Practice address
17724 I 30 Ste 2 Ofc 5
Benton, AR 72019-2907
Phone
(501) 400-6570
NPI assigned
Jan 13, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Elizabeth Ruggiero Wallis, PHD
Title
Therapist
Phone
(501) 400-6570

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Preferred Provider Organization 305R00000X PO807061 AR Primary
Preferred Provider Organization 305R00000X MO704002 AR

Addresses

Primary practice location

17724 I 30 Ste 2 Ofc 5
Benton, AR 72019-2907

Mailing address

PO Box 897
Benton, AR 72018-0897
Phone (501) 400-6570

Other identifiers 1

IdentifierTypeStateIssuer
1699966697OtherARNPI

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1484265600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1561334400000",
    "number": "1871039883",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 897",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720180897",
            "telephone_number": "501-400-6570"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17724 I 30 STE 2 OFC 5",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720192907",
            "telephone_number": "501-400-6570"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SYSTEMIC FAMILY THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-13",
        "last_updated": "2019-06-24",
        "status": "A",
        "authorized_official_last_name": "WALLIS",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "RUGGIERO",
        "authorized_official_title_or_position": "THERAPIST",
        "authorized_official_telephone_number": "501-400-6570",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "AR",
            "license": "PO807061",
            "primary": true
        },
        {
            "code": "305R00000X",
            "taxonomy_group": "",
            "desc": "Preferred Provider Organization",
            "state": "AR",
            "license": "MO704002",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1699966697",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Benton, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.