MEDICARE: FAITH JOANN BERRY 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	101YM0800X	Mental Health Counselor	A0308072	AR

General Provider Information

NPI Number	:	1831127075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAITH JOANN BERRY LAC

Provider Business Mailing Address
First Line	:	4253 N CROSSOVER RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4593
Country	:	US
Telephone Number	:	479-521-5731
Fax Number	:	479-521-4926

Provider Business Practice Location Address
First Line	:	4253 N CROSSOVER RD
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4593
Country	:	US
Telephone Number	:	479-443-6496
Fax Number	:	479-521-4926

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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Directions to “ FAITH JOANN BERRY LAC” Practice Location

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