Provider Demographics
NPI:1871750950
Name:RUST, PAUL WESLEY (LCSW)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:WESLEY
Last Name:RUST
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 ROGERS AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2047
Mailing Address - Country:US
Mailing Address - Phone:479-484-1111
Mailing Address - Fax:479-484-1111
Practice Address - Street 1:5111 ROGERS AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2047
Practice Address - Country:US
Practice Address - Phone:479-484-1111
Practice Address - Fax:479-484-1111
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2008-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR237C1041C0700X
ARM980314106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S069Medicare PIN