Provider Demographics
NPI:1366806945
Name:RESURGENT MHT
Entity type:Organization
Organization Name:RESURGENT MHT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WLEKLINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:479-220-2772
Mailing Address - Street 1:324 RAVENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-5550
Mailing Address - Country:US
Mailing Address - Phone:479-220-2772
Mailing Address - Fax:
Practice Address - Street 1:593 S HORSEBARN RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8795
Practice Address - Country:US
Practice Address - Phone:479-657-4636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003818261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health