Healthcare Provider Details

I. General information

NPI: 1184732794
Provider Name (Legal Business Name): MARY ANN MERNAUGH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. MARY ANN DIMATTIO

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714-A ASHFLAT DRIVE
ASHFLAT AR AR
72513
US

IV. Provider business mailing address

PO BOX 2578
BATESVILLE AR
72503-2578
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-2106
  • Fax: 870-994-7868
Mailing address:
  • Phone: 870-994-2106
  • Fax: 870-994-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP0507049
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: