Healthcare Provider Details

I. General information

NPI: 1841477866
Provider Name (Legal Business Name): STACIE MACKEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3214 WINCHESTER
BENTON AR
72015-2929
US

IV. Provider business mailing address

3214 WINCHESTER
BENTON AR
72015-2929
US

V. Phone/Fax

Practice location:
  • Phone: 501-326-6160
  • Fax: 501-326-6161
Mailing address:
  • Phone: 501-326-6160
  • Fax: 501-326-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA0810082
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1109065
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: