Healthcare Provider Details

I. General information

NPI: 1457594848
Provider Name (Legal Business Name): PRISCILLA ANN FAULKNER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 MAIN AVE
DIERKS AR
71833-9421
US

IV. Provider business mailing address

PO BOX 575
DIERKS AR
71833-0575
US

V. Phone/Fax

Practice location:
  • Phone: 187-028-5141
  • Fax: 870-825-2060
Mailing address:
  • Phone: 870-285-1413
  • Fax: 870-230-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA1003032
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: