Healthcare Provider Details

I. General information

NPI: 1992533921
Provider Name (Legal Business Name): MARY CATHERINE ROSE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOTE CATHERINE MARY

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 W FREEMAN AVE STE 9
BERRYVILLE AR
72616-3141
US

IV. Provider business mailing address

804 W FREEMAN AVE STE 9
BERRYVILLE AR
72616-3141
US

V. Phone/Fax

Practice location:
  • Phone: 870-340-2636
  • Fax:
Mailing address:
  • Phone: 870-340-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2407006
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: