Healthcare Provider Details

I. General information

NPI: 1013607217
Provider Name (Legal Business Name): VERONICA OZURA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 MAIN AVE
DIERKS AR
71833-9421
US

IV. Provider business mailing address

PO BOX 525
DIERKS AR
71833-0525
US

V. Phone/Fax

Practice location:
  • Phone: 870-584-9568
  • Fax:
Mailing address:
  • Phone: 870-784-0884
  • Fax: 870-825-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA2305005
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: