Healthcare Provider Details

I. General information

NPI: 1417175159
Provider Name (Legal Business Name): MISTY LEANNE JUOLA LPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY E WITHERINGTON LPE

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W SOUTH ST. ACA
BENTON AR
72015
US

IV. Provider business mailing address

109 W SOUTH ST. ACA - ARKANSAS COUNSELING ASSOCCIATES
BENTON AR
72015
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-1191
  • Fax: 501-776-1194
Mailing address:
  • Phone: 501-776-1191
  • Fax: 501-776-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number01-21E
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: