Healthcare Provider Details

I. General information

NPI: 1962349001
Provider Name (Legal Business Name): PATRICK LASHANE GILLETTE JR. LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W WASHINGTON ST # B
CAMDEN AR
71701-3380
US

IV. Provider business mailing address

810 W WASHINGTON ST # B
CAMDEN AR
71701-3380
US

V. Phone/Fax

Practice location:
  • Phone: 501-802-0107
  • Fax: 888-892-4015
Mailing address:
  • Phone: 501-802-0107
  • Fax: 888-892-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2604012
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: