NPI 1053656108
Theodore Gongola
Practice location
- Address
- 3205 W Main St, Russellville, AR 72801-2301
- Phone
- (479) 967-4673
- Fax
- (479) 967-7140
- Mailing address
- 602 N Walton Blvd, Bentonville, AR 72712-4576
Registered specialties
Counselor
Primary
Registry record
- NPI
- 1053656108
- Entity type
- Individual
- Sex (as registered)
- Male
- NPI issued
- 30 Nov 2012
- Record last updated
- 30 Nov 2012
Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.