MEDICARE: DILLON WEBSTER LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		AR
2	101YM0800X	Mental Health Counselor	A2208028	AR

General Provider Information

NPI Number	:	1346665650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DILLON WEBSTER LAC

Provider Business Mailing Address
First Line	:	1220 E DATE ST
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72802-7718
Country	:	US
Telephone Number	:	479-970-4844
Fax Number	:

Provider Business Practice Location Address
First Line	:	1310 W MAIN ST STE 100
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72801-2803
Country	:	US
Telephone Number	:	479-964-2011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2014
Last Update Date	:	10/04/2022

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Directions to “ DILLON WEBSTER LAC” Practice Location

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